Healthcare Provider Details

I. General information

NPI: 1619424264
Provider Name (Legal Business Name): DR. TIMOTHY GROSS' DENTAL EXCELLENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BOW CIR SUITE 104
HILTON HEAD ISLAND SC
29928-3211
US

IV. Provider business mailing address

15 BOW CIRCLE SUITE 104
HILTON HEAD ISLAND SC
29928-3211
US

V. Phone/Fax

Practice location:
  • Phone: 843-342-7700
  • Fax: 843-785-7804
Mailing address:
  • Phone: 843-342-7700
  • Fax: 843-785-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDGD4552
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY PAUL GROSS
Title or Position: OWNER/DOCTOR
Credential: D.M.D.
Phone: 843-342-7700