Provider Demographics
NPI:1790055804
Name:GORDON S. GROISSER, DDS, MSD
Entity Type:Organization
Organization Name:GORDON S. GROISSER, DDS, MSD
Other - Org Name:VILLAGE ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:GROISSER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:301-393-2680
Mailing Address - Street 1:18638 CRESTWOOD DRIVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:301-393-2680
Mailing Address - Fax:301-393-2682
Practice Address - Street 1:18638 CRESTWOOD DRIVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-393-2680
Practice Address - Fax:301-393-2682
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GORDON S. GROISSER, DDS, MSD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD135071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty