MEDICARE: DR. KEITH ROGER GRONBACH 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	44317	CA

General Provider Information

NPI Number	:	1992853204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH ROGER GRONBACH D.D.S.

Provider Business Mailing Address
First Line	:	3799 MT DIABLO BLVD
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3538
Country	:	US
Telephone Number	:	925-283-4050
Fax Number	:	925-283-5340

Provider Business Practice Location Address
First Line	:	3799 MT DIABLO BLVD
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3538
Country	:	US
Telephone Number	:	925-283-4050
Fax Number	:	925-283-5340

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/22/2020

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