Healthcare Provider Details

I. General information

NPI: 1366173551
Provider Name (Legal Business Name): 110 REGENT COURT COLLEGE PROFESSIONAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 REGENT CT STE 100
STATE COLLEGE PA
16801-7966
US

IV. Provider business mailing address

110 REGENT CT STE 100
STATE COLLEGE PA
16801-7966
US

V. Phone/Fax

Practice location:
  • Phone: 814-231-0110
  • Fax: 814-231-0118
Mailing address:
  • Phone: 814-231-0110
  • Fax: 814-231-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER GRUMBOS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 505-722-4422