Provider Demographics
NPI:1093891764
Name:ROZENOVICH, GRIGORY (DDS)
Entity Type:Individual
Prefix:
First Name:GRIGORY
Middle Name:
Last Name:ROZENOVICH
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 1:3620 S. BRISTOL ST. SUITE 210
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704
Mailing Address - Country:US
Mailing Address - Phone:714-549-1409
Mailing Address - Fax:714-549-2118
Practice Address - Street 1:3620 S. BRISTOL ST. SUITE 210
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:714-549-1409
Practice Address - Fax:714-549-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD401151223G0001X
CA401151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice