1265614861 NPI number — DR. MARK L GROSKO D.D.S.

Table of content: DR. MARK L GROSKO D.D.S. (NPI 1265614861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265614861 NPI number — DR. MARK L GROSKO D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSKO
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265614861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
843 N 21ST ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43055-7273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-344-6349
Provider Business Mailing Address Fax Number:
740-344-6350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
843 N 21ST ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43055-7273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-344-6349
Provider Business Practice Location Address Fax Number:
740-344-6350
Provider Enumeration Date:
12/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  21555 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 440265 . This is a "SUPERIOR DENTAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2424693 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256022 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9185647 . This is a "DORAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1400162 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 187028 . This is a "COMP BENEFITS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 25 1901759027 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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