Provider Demographics
NPI:1407110984
Name:GROSEL, MAX AUSTIN (DDS)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:AUSTIN
Last Name:GROSEL
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 1:4241 KIMBERLY PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-7225
Mailing Address - Country:US
Mailing Address - Phone:614-866-7445
Mailing Address - Fax:
Practice Address - Street 1:4241 KIMBERLY PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-7225
Practice Address - Country:US
Practice Address - Phone:614-866-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist