Provider Demographics
NPI: | 1164697074 |
---|---|
Name: | ROBERT A. GRUENBERG DDS |
Entity Type: | Organization |
Organization Name: | ROBERT A. GRUENBERG DDS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MGR |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | PAMALA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CANTWELL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 918-342-3477 |
Mailing Address - Street 1: | 133 W BLUE STARR DR |
Mailing Address - Street 2: | |
Mailing Address - City: | CLAREMORE |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74017-4226 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 918-342-3477 |
Mailing Address - Fax: | 918-341-9670 |
Practice Address - Street 1: | 133 W BLUE STARR DR |
Practice Address - Street 2: | |
Practice Address - City: | CLAREMORE |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74017-4226 |
Practice Address - Country: | US |
Practice Address - Phone: | 918-342-3477 |
Practice Address - Fax: | 918-341-9670 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-04-23 |
Last Update Date: | 2008-04-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OK | 4601 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |