Healthcare Provider Details

I. General information

NPI: 1811827074
Provider Name (Legal Business Name): ETHAN J GROEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 E 200 N STE 3
LOGAN UT
84321-4049
US

IV. Provider business mailing address

265 S 375 W
PROVIDENCE UT
84332-9308
US

V. Phone/Fax

Practice location:
  • Phone: 435-363-3584
  • Fax:
Mailing address:
  • Phone: 385-630-3788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: