Provider Demographics
NPI:1629234018
Name:GROGANS MILL DENTAL, PC
Entity Type:Organization
Organization Name:GROGANS MILL DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:281-298-5225
Mailing Address - Street 1:19 IVORY MOON PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-6441
Mailing Address - Country:US
Mailing Address - Phone:469-713-7936
Mailing Address - Fax:
Practice Address - Street 1:25210 GROGANS MILL RD
Practice Address - Street 2:STE A
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2378
Practice Address - Country:US
Practice Address - Phone:281-298-5225
Practice Address - Fax:281-298-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL48421223G0001X
TX230151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty