Provider Demographics
NPI:1417954629
Name:GROSS, PAUL DWAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DWAYNE
Last Name:GROSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 HIGHWAY 321 N UNIT 20 BLDG 4
Mailing Address - Street 2:LENOIR CITY PROF. PARK
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37771-6575
Mailing Address - Country:US
Mailing Address - Phone:865-986-4582
Mailing Address - Fax:865-988-8398
Practice Address - Street 1:603 HIGHWAY 321 N UNIT 20 BLDG 4
Practice Address - Street 2:LENOIR CITY PROF. PARK
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-6575
Practice Address - Country:US
Practice Address - Phone:865-986-4582
Practice Address - Fax:865-988-8398
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS24951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225912Medicaid
TNU40346Medicare UPIN
TN3225912Medicaid