MEDICARE: DENISE L GROSS

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	335E00000X	Prosthetic/Orthotic Supplier	1474782	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33-1035302	OTHER	TX	NON-SURGICAL HAIR REPLACEMENT

General Provider Information

NPI Number	:	1477311322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE L GROSS

Provider Business Mailing Address
First Line	:	7300 MOON RIDGE CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-8335
Country	:	US
Telephone Number	:	682-371-8289
Fax Number	:

Provider Business Practice Location Address
First Line	:	7300 MOON RIDGE CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-8335
Country	:	US
Telephone Number	:	682-371-8289
Fax Number	:

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

Provider Enumeration Date	:	03/06/2024
Last Update Date	:	03/06/2024

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Directions to “ DENISE L GROSS ” Practice Location

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