Provider Demographics
NPI:1720562150
Name:GROSE, TYSON CRAIG (DMD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:CRAIG
Last Name:GROSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-1328
Mailing Address - Country:US
Mailing Address - Phone:970-335-2238
Mailing Address - Fax:970-335-2438
Practice Address - Street 1:101 S MAPLE ST STE B
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3562
Practice Address - Country:US
Practice Address - Phone:970-565-1800
Practice Address - Fax:833-245-0111
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10854655-9922122300000X
CODEN.00203984122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist