Provider Demographics
NPI:1255483806
Name:GOSS, GRADY MACK (DMD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:MACK
Last Name:GOSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 PARKS AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768
Mailing Address - Country:US
Mailing Address - Phone:256-259-1746
Mailing Address - Fax:256-259-0017
Practice Address - Street 1:313 PARKS AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768
Practice Address - Country:US
Practice Address - Phone:256-259-1746
Practice Address - Fax:256-259-0017
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2757122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist