Provider Demographics
NPI:1164764718
Name:GROSSMAN, WALTER S (DDS)
Entity Type:Individual
Prefix:
First Name:WALTER
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 1:20575 CENTER RIDGE ROAD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-333-4987
Mailing Address - Fax:440-333-4986
Practice Address - Street 1:20575 CENTER RIDGE ROAD
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116
Practice Address - Country:US
Practice Address - Phone:440-333-4987
Practice Address - Fax:440-333-4986
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1912066366Medicaid