=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437887049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEREMY M GROVE DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2022
-----------------------------------------------------
Last Update Date | 08/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S BRIDGE ST.
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-735-7511
-----------------------------------------------------
Fax | 810-735-0918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 127 501 S BRIDGE ST.
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-735-7511
-----------------------------------------------------
Fax | 810-735-0918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | JEREMY MARSHALL GROVE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 810-725-7511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------