Provider Demographics
NPI:1235262031
Name:GRUD, STEPHEN JOHN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:GRUD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2244
Mailing Address - Country:US
Mailing Address - Phone:708-484-7453
Mailing Address - Fax:708-484-7574
Practice Address - Street 1:6900 CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2244
Practice Address - Country:US
Practice Address - Phone:708-484-7453
Practice Address - Fax:708-484-7574
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL21-0016791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics