Provider Demographics
NPI:1750312930
Name:GROSSMAN, RICHARD REID (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:REID
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:REID
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, PC
Mailing Address - Street 1:489 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4534
Mailing Address - Country:US
Mailing Address - Phone:570-283-0664
Mailing Address - Fax:570-283-5623
Practice Address - Street 1:489 MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-4534
Practice Address - Country:US
Practice Address - Phone:570-283-0664
Practice Address - Fax:570-283-5623
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020564L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005204860002Medicaid