Provider Demographics
NPI:1417019746
Name:GROSS, SHEPHERD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHEPHERD
Middle Name:
Last Name:GROSS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHEPHERD
Other - Middle Name:
Other - Last Name:GROSS
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1947 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430
Mailing Address - Country:US
Mailing Address - Phone:708-957-5836
Mailing Address - Fax:708-957-5818
Practice Address - Street 1:1947 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430
Practice Address - Country:US
Practice Address - Phone:708-957-5836
Practice Address - Fax:708-957-5818
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BG4748426OtherFED DEA