Provider Demographics
NPI:1235590787
Name:GROCK, SIMON (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:GROCK
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 1:4553 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:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist