Provider Demographics
NPI:1639599962
Name:DAXON & GRUNDSET PLLC
Entity Type:Organization
Organization Name:DAXON & GRUNDSET PLLC
Other - Org Name:DAXON & GRUNDSET DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNDEST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-282-1970
Mailing Address - Street 1:111 2ND AVE NE STE 1104
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3443
Mailing Address - Country:US
Mailing Address - Phone:727-282-1970
Mailing Address - Fax:727-608-1980
Practice Address - Street 1:111 2ND AVE NE STE 1104
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3443
Practice Address - Country:US
Practice Address - Phone:727-282-1970
Practice Address - Fax:727-608-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 04596261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental