Healthcare Provider Details

I. General information

NPI: 1134365554
Provider Name (Legal Business Name): GRONSTEN-MAIER DENTAL PROF. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 07/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E. 23RD AVENUE
MITCHELL SD
57301
US

IV. Provider business mailing address

240 E. 23RD AVENUE
MITCHELL SD
57301
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-1316
  • Fax: 605-996-6629
Mailing address:
  • Phone: 605-996-1316
  • Fax: 605-996-6629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM873
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CODY EUGENE GRONSTEN
Title or Position: OWNER
Credential: DDS
Phone: 605-996-1316