Provider Demographics
NPI:1033363403
Name:GRUBB, ROLAND N (DDS)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:N
Last Name:GRUBB
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:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:WILLOW CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95573-1125
Mailing Address - Country:US
Mailing Address - Phone:530-629-2155
Mailing Address - Fax:
Practice Address - Street 1:40618 HWY 299
Practice Address - Street 2:
Practice Address - City:WILLOW CREEK
Practice Address - State:CA
Practice Address - Zip Code:95573
Practice Address - Country:US
Practice Address - Phone:530-629-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice