MEDICARE: BEVERLY ANN GROSS RDH

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	124Q00000X	Dental Hygienist	2902004756	MI

General Provider Information

NPI Number	:	1255853669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY ANN GROSS RDH

Provider Business Mailing Address
First Line	:	1384 INDIAN MOUND E
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-2254
Country	:	US
Telephone Number	:	248-931-7832
Fax Number	:

Provider Business Practice Location Address
First Line	:	1384 INDIAN MOUND E
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-2254
Country	:	US
Telephone Number	:	248-931-7832
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2017
Last Update Date	:	07/21/2022

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