Provider Demographics
NPI:1336331990
Name:DR. ROY L. GROB, INC
Entity Type:Organization
Organization Name:DR. ROY L. GROB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GROB
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:985-626-4779
Mailing Address - Street 1:2245 11TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6497
Mailing Address - Country:US
Mailing Address - Phone:985-626-4779
Mailing Address - Fax:985-626-4779
Practice Address - Street 1:2245 11TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6497
Practice Address - Country:US
Practice Address - Phone:985-626-4779
Practice Address - Fax:985-626-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0082058Medicaid