MEDICARE: DR. LESLIE RAYMOND GROSS D.D.S.

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	122300000X	Dentist	DS035483	PA

General Provider Information

NPI Number	:	1477686962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE RAYMOND GROSS D.D.S.

Provider Business Mailing Address
First Line	:	777 W GERMANTOWN PIKE APT 923
Second Line	:
City	:	PLYMOUTH MEETING
State	:	PA
Zip	:	19462-1022
Country	:	US
Telephone Number	:	610-279-7292
Fax Number	:

Provider Business Practice Location Address
First Line	:	722 MARKET ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-2312
Country	:	US
Telephone Number	:	215-922-5101
Fax Number	:

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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