Provider Demographics
NPI:1184034894
Name:SIMON GROCK DDS APC
Entity Type:Organization
Organization Name:SIMON GROCK DDS APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP.PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:GROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-384-3404
Mailing Address - Street 1:4553 GLENCOE AVE # 310
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7906
Mailing Address - Country:US
Mailing Address - Phone:310-384-3404
Mailing Address - Fax:
Practice Address - Street 1:4553 GLENCOE AVE # 310
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7906
Practice Address - Country:US
Practice Address - Phone:310-384-3404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-02
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty