Provider Demographics
NPI:1578885141
Name:DENTAL PRACTICE OF DRS. MCKELVEY & GROSSMAN, A PROF. DENTAL CORP.
Entity Type:Organization
Organization Name:DENTAL PRACTICE OF DRS. MCKELVEY & GROSSMAN, A PROF. DENTAL CORP.
Other - Org Name:TWAIN HARTE FAMILY DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-586-2772
Mailing Address - Street 1:22629 TWAIN HARTE DR
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9405
Mailing Address - Country:US
Mailing Address - Phone:209-586-2772
Mailing Address - Fax:
Practice Address - Street 1:22629 TWAIN HARTE DR
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9405
Practice Address - Country:US
Practice Address - Phone:209-586-2772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty