Provider Demographics
NPI:1629111257
Name:GROSS, DANIEL MARC (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARC
Last Name:GROSS
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 1:11401 201ST ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2810
Mailing Address - Country:US
Mailing Address - Phone:718-464-2138
Mailing Address - Fax:718-464-4358
Practice Address - Street 1:11401 201ST ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2810
Practice Address - Country:US
Practice Address - Phone:718-464-2138
Practice Address - Fax:718-464-4358
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033015-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY243Medicaid
NYA7551OtherHEALTHPLEX SITE #
NY00842484Medicaid