Provider Demographics
NPI:1477641835
Name:GROSSO, TYLER N (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:N
Last Name:GROSSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9205 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-2428
Mailing Address - Country:US
Mailing Address - Phone:718-843-5544
Mailing Address - Fax:718-843-0747
Practice Address - Street 1:9205 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-2428
Practice Address - Country:US
Practice Address - Phone:718-843-5544
Practice Address - Fax:718-843-0747
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50-0496671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice