Provider Demographics
NPI:1447605886
Name:GROSDIDIER, WILLIAM
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:GROSDIDIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 17314
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368
Practice Address - Country:JP
Practice Address - Phone:315-630-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13681122300000X, 1223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program