Provider Demographics
NPI:1144354713
Name:GROSSMAN, JAY S (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:S
Last Name:GROSSMAN
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 1:11980 SAN VICENTE BLVD STE 507
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6603
Mailing Address - Country:US
Mailing Address - Phone:310-820-0123
Mailing Address - Fax:310-207-3784
Practice Address - Street 1:11980 SAN VICENTE BLVD STE 507
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6603
Practice Address - Country:US
Practice Address - Phone:310-820-0123
Practice Address - Fax:310-207-3784
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA386861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice