Provider Demographics
NPI:1437285012
Name:STEPHEN L GROSS DDS PC
Entity Type:Organization
Organization Name:STEPHEN L GROSS DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-223-8262
Mailing Address - Street 1:204 W THAYER AVE
Mailing Address - Street 2:SUITE B2
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3772
Mailing Address - Country:US
Mailing Address - Phone:701-223-8262
Mailing Address - Fax:701-223-0733
Practice Address - Street 1:204 W THAYER AVE
Practice Address - Street 2:SUITE B2
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3772
Practice Address - Country:US
Practice Address - Phone:701-223-8262
Practice Address - Fax:701-223-0733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40999Medicaid