Provider Demographics
NPI:1588809545
Name:HEATH A. GROTE, DMD, PC
Entity Type:Organization
Organization Name:HEATH A. GROTE, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GROTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-352-5809
Mailing Address - Street 1:2916 CROSSING COURT
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822
Mailing Address - Country:US
Mailing Address - Phone:217-352-5809
Mailing Address - Fax:217-352-5812
Practice Address - Street 1:2916 CROSSING COURT
Practice Address - Street 2:SUITE C
Practice Address - City:CHAMPIAGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-352-5809
Practice Address - Fax:217-352-5812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223E0200X
IL0190241321223E0200X
IL0190258711223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty