Provider Demographics
NPI:1417637596
Name:GRUBOR, NICHOLAS BANKS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:BANKS
Last Name:GRUBOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 LAKESHORE DR N
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7707
Mailing Address - Country:US
Mailing Address - Phone:904-460-4911
Mailing Address - Fax:
Practice Address - Street 1:1805 BLANDING BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3839
Practice Address - Country:US
Practice Address - Phone:904-214-3476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL283831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice