MEDICARE: WYOMISSING DENTAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS017881L	PA

General Provider Information

NPI Number	:	1104031756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYOMISSING DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	1286 PENN AVE
Second Line	:
City	:	WYOMISSING
State	:	PA
Zip	:	19610-2130
Country	:	US
Telephone Number	:	610-372-8406
Fax Number	:	610-372-3998

Provider Business Practice Location Address
First Line	:	1286 PENN AVE
Second Line	:
City	:	WYOMISSING
State	:	PA
Zip	:	19610-2130
Country	:	US
Telephone Number	:	610-372-8406
Fax Number	:	610-372-3998

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DALE W. GROVE
Credential	:	D.M.D.
Telephone Number	:	610-372-8406

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	08/22/2020

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Practice Location Address:

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1326196023 — DALE W GROVE D.M.D.
Practice Location Address:

1286 PENN AVE
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19610-2130

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Practice Location Address:

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