Healthcare Provider Details

I. General information

NPI: 1225580962
Provider Name (Legal Business Name): JESSE GROSSMAN RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 6TH ST
CLARKSTON WA
99403-2013
US

IV. Provider business mailing address

844 6TH ST
CLARKSTON WA
99403-2013
US

V. Phone/Fax

Practice location:
  • Phone: 208-848-8300
  • Fax: 208-848-8306
Mailing address:
  • Phone: 208-848-8300
  • Fax: 208-848-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH60682830
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: