Provider Demographics
NPI:1619424264
Name:DR. TIMOTHY GROSS' DENTAL EXCELLENCE LLC
Entity Type:Organization
Organization Name:DR. TIMOTHY GROSS' DENTAL EXCELLENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-342-7700
Mailing Address - Street 1:15 BOW CIRCLE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-3211
Mailing Address - Country:US
Mailing Address - Phone:843-342-7700
Mailing Address - Fax:843-785-7804
Practice Address - Street 1:15 BOW CIR
Practice Address - Street 2:SUITE 104
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-3211
Practice Address - Country:US
Practice Address - Phone:843-342-7700
Practice Address - Fax:843-785-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD4552122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty