Provider Demographics
NPI:1326318254
Name:WYOMISSING DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:WYOMISSING DENTAL ASSOCIATES, P.C.
Other - Org Name:GROVE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-372-8406
Mailing Address - Street 1:2228 STATE HILL RD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1904
Mailing Address - Country:US
Mailing Address - Phone:610-372-8406
Mailing Address - Fax:610-372-3998
Practice Address - Street 1:2228 STATE HILL RD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1904
Practice Address - Country:US
Practice Address - Phone:610-372-8406
Practice Address - Fax:610-372-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0361141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty