Provider Demographics
NPI:1083789507
Name:GROVE ENDODONTICS, P.A.
Entity Type:Organization
Organization Name:GROVE ENDODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALDRON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-768-8180
Mailing Address - Street 1:8811 92ND ST S
Mailing Address - Street 2:SUITE 109
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4036
Mailing Address - Country:US
Mailing Address - Phone:651-768-8180
Mailing Address - Fax:651-768-8184
Practice Address - Street 1:8811 92ND ST S
Practice Address - Street 2:SUITE 109
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4036
Practice Address - Country:US
Practice Address - Phone:651-768-8180
Practice Address - Fax:651-768-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND109811223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty