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General NPI Number Information
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NPI Number | 1912196171
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Entity Type | Organization
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Legal Business Name | GRIGORY ROZENVICH D.D.S., INC.
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Dates
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Enumeration Date | 10/23/2007
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Last Update Date | 05/06/2015
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Provider Practice Location Address
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Address Line | 3620 S. BRISTOL ST. SUITE 210
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City | SANTA ANA
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State | CA
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Zip | 92704
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Country | US
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Telephone | 714-549-1409
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Fax | 714-549-2118
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Provider Business Mailing Address
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Address Line | 3620 S. BRISTOL ST. SUITE 210
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City | SANTA ANA
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State | CA
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Zip | 92704
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Country | US
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Telephone | 714-549-1409
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Fax | 714-549-2118
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Authorized Official
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Title or Position | PRESIDENT
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Name | GRIGORY ROZENOVICH
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Credential |
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Telephone | 714-549-1409
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 40115
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License Number State | CA
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