Provider Demographics
NPI:1619170099
Name:GROVE, JENNIFER LEIGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LEIGH
Last Name:GROVE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 S 3RD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-8878
Mailing Address - Country:US
Mailing Address - Phone:515-986-4001
Mailing Address - Fax:515-986-4037
Practice Address - Street 1:1541 S THIRD STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111
Practice Address - Country:US
Practice Address - Phone:515-986-4001
Practice Address - Fax:515-986-4037
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA83581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0470781Medicaid