1548482300 NPI number — GORDON D. GROSS, D.D.S.,P.C.

Table of content: (NPI 1548482300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548482300 NPI number — GORDON D. GROSS, D.D.S.,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDON D. GROSS, D.D.S.,P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1548482300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2715 W NORTHERN AVE
Provider Second Line Business Mailing Address:
#102
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85051-6641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-995-0280
Provider Business Mailing Address Fax Number:
602-864-9161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2715 W NORTHERN AVE
Provider Second Line Business Practice Location Address:
#102
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85051-6641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-995-0280
Provider Business Practice Location Address Fax Number:
602-864-9161
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-995-0280

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 824144 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com