=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184734857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRA BRAD GROSSER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 N VILLAGE AVE SUITE 106 DR IRA GROSSER
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-3761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-766-1877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 165 N VILLAGE AVE SUITE 106 DR IRA GROSSER
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570-3761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-766-1877
-----------------------------------------------------
Fax | 516-766-3544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 038178
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------