=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093808594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEITH R. GRONBACH, D.D.S., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 07/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3799 MT DIABLO BLVD
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-3538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-283-4050
-----------------------------------------------------
Fax | 925-283-5340
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3799 MT DIABLO BLVD
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-3538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-283-4050
-----------------------------------------------------
Fax | 925-283-5340
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KEITH R. GRONBACH
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 925-283-4050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 44317
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------