1619424264 NPI number — DR. TIMOTHY GROSS' DENTAL EXCELLENCE LLC

Table of content: (NPI 1619424264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619424264 NPI number — DR. TIMOTHY GROSS' DENTAL EXCELLENCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. TIMOTHY GROSS' DENTAL EXCELLENCE LLC
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:
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:
1619424264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 BOW CIRCLE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
HILTON HEAD ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29928-3211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-342-7700
Provider Business Mailing Address Fax Number:
843-785-7804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 BOW CIR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
HILTON HEAD ISLAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29928-3211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-342-7700
Provider Business Practice Location Address Fax Number:
843-785-7804
Provider Enumeration Date:
09/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GROSS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER/DOCTOR
Authorized Official Telephone Number:
843-342-7700

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: DGD4552 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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