Provider Demographics
NPI:1073382099
Name:ETHAN GROUNDS DMD PC
Entity Type:Organization
Organization Name:ETHAN GROUNDS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-889-0606
Mailing Address - Street 1:910 MARSHALL STREET
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946
Mailing Address - Country:US
Mailing Address - Phone:618-889-0606
Mailing Address - Fax:
Practice Address - Street 1:300 SMALL ST STE D
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-3325
Practice Address - Country:US
Practice Address - Phone:618-252-1725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental