Provider Demographics
NPI:1629557012
Name:GROSS, ANDREW JACOB (PHD, DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JACOB
Last Name:GROSS
Suffix:
Gender:M
Credentials:PHD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST BLDG SUITE230
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-726-2740
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST., WANG AMBULATORY BLDG SUITE230
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-2740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10858402-89031223G0001X
TN110221223S0112X
UT10858402-99251223S0112X
MADN18597641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty