Provider Demographics
NPI:1790832368
Name:GROSSMAN, PAUL T (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:T
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 GRANGER FARM WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-8641
Mailing Address - Country:US
Mailing Address - Phone:702-355-2487
Mailing Address - Fax:
Practice Address - Street 1:1008 GRANGER FARM WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8641
Practice Address - Country:US
Practice Address - Phone:702-355-2487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202046Medicaid