Provider Demographics
NPI:1497935241
Name:GROSSO, GWEN MARIE (RDH)
Entity Type:Individual
Prefix:MISS
First Name:GWEN
Middle Name:MARIE
Last Name:GROSSO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 KEELER RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:CT
Mailing Address - Zip Code:06752-1331
Mailing Address - Country:US
Mailing Address - Phone:860-350-4768
Mailing Address - Fax:
Practice Address - Street 1:419 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-1918
Practice Address - Country:US
Practice Address - Phone:203-479-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003998124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist