Provider Demographics
NPI:1073599304
Name:GROTSTEIN, JERALD ALLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:ALLEN
Last Name:GROTSTEIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIDGE VIEW DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-5589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 RIDGE VIEW DR
Practice Address - Street 2:SUITE 103
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5589
Practice Address - Country:US
Practice Address - Phone:919-467-2203
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC93434Medicaid