Provider Demographics
NPI:1144398009
Name:GROSS, SUSAN GAIL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GAIL
Last Name:GROSS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5009 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE #124
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3041
Mailing Address - Country:US
Mailing Address - Phone:952-926-0020
Mailing Address - Fax:952-926-0417
Practice Address - Street 1:5009 EXCELSIOR BLVD
Practice Address - Street 2:SUITE #124
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3041
Practice Address - Country:US
Practice Address - Phone:952-926-0020
Practice Address - Fax:952-926-0417
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN93311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice