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General NPI Number Information
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NPI Number | 1609176999
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Entity Type | Organization
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Legal Business Name | GROSSE DMD INC.
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Dates
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Enumeration Date | 11/02/2010
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Last Update Date | 11/02/2010
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Provider Practice Location Address
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Address Line | 3939 W FULLERTON AVE
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City | CHICAGO
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State | IL
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Zip | 60647-2243
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Country | US
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Telephone | 773-235-0000
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Fax |
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Provider Business Mailing Address
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Address Line | 849 N FRANKLIN ST UNIT 1104
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City | CHICAGO
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State | IL
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Zip | 60610-8793
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Country | US
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Telephone | 309-472-0645
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Fax |
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. GINA LEIGH GROSSE
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Credential | D.M.D.
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Telephone | 309-472-0645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019027794
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License Number State | IL
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