Provider Demographics
NPI:1548200678
Name:GROAT, DAVID ANTHONY (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTHONY
Last Name:GROAT
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 1:1300 KURT DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-9324
Mailing Address - Country:US
Mailing Address - Phone:209-736-0458
Mailing Address - Fax:209-736-4858
Practice Address - Street 1:1300 KURT DR STE 101
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222-9324
Practice Address - Country:US
Practice Address - Phone:209-736-0458
Practice Address - Fax:209-736-4858
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33771OtherSTATE DENTAL LICENSE