Provider Demographics
NPI:1518003094
Name:GRUBB, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:GRUBB
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 1:91 JUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2521
Mailing Address - Country:US
Mailing Address - Phone:207-945-5353
Mailing Address - Fax:
Practice Address - Street 1:37 BOWER ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4721
Practice Address - Country:US
Practice Address - Phone:207-945-5691
Practice Address - Fax:207-942-9525
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME33401223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MET93694Medicare UPIN
MEMM3050Medicare ID - Type Unspecified