Provider Demographics
NPI:1043639230
Name:DOUGLAS M GROSMARK DMD INCORPORATED
Entity Type:Organization
Organization Name:DOUGLAS M GROSMARK DMD INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-286-1181
Mailing Address - Street 1:6398 DEL CERRO BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4760
Mailing Address - Country:US
Mailing Address - Phone:619-286-1181
Mailing Address - Fax:619-286-1438
Practice Address - Street 1:6398 DEL CERRO BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4760
Practice Address - Country:US
Practice Address - Phone:619-286-1181
Practice Address - Fax:619-286-1438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty