Provider Demographics
NPI:1013012483
Name:GRODNER, ROBERT WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:GRODNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10207 WILLOWGROVE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-3421
Mailing Address - Country:US
Mailing Address - Phone:505-363-9215
Mailing Address - Fax:
Practice Address - Street 1:3701 KIRBY DR STE 550
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-3926
Practice Address - Country:US
Practice Address - Phone:713-490-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11161223G0001X
TX367601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM83360Medicaid