Provider Demographics
NPI:1659896827
Name:GRANT ROAD DENTAL
Entity Type:Organization
Organization Name:GRANT ROAD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-938-8127
Mailing Address - Street 1:15075 LOS GATOS BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2049
Mailing Address - Country:US
Mailing Address - Phone:408-884-8155
Mailing Address - Fax:408-252-1904
Practice Address - Street 1:1040 GRANT RD STE 105
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3274
Practice Address - Country:US
Practice Address - Phone:650-938-8127
Practice Address - Fax:650-230-4925
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOS GATOS DENTAL SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335121223G0001X
1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty