Provider Demographics
NPI:1326481284
Name:GROVE DENTIST PA
Entity Type:Organization
Organization Name:GROVE DENTIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-308-2804
Mailing Address - Street 1:13649 GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4405
Mailing Address - Country:US
Mailing Address - Phone:763-420-8038
Mailing Address - Fax:763-494-4222
Practice Address - Street 1:13649 GROVE DR
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4405
Practice Address - Country:US
Practice Address - Phone:763-420-8038
Practice Address - Fax:763-494-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND118441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty