Provider Demographics
NPI:1821260951
Name:GROUSD, MICHAEL H (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
Last Name:GROUSD
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:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:TUBAC
Mailing Address - State:AZ
Mailing Address - Zip Code:85646-1450
Mailing Address - Country:US
Mailing Address - Phone:520-310-4705
Mailing Address - Fax:
Practice Address - Street 1:1360 W IRVINGTON RD STE 180
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-4102
Practice Address - Country:US
Practice Address - Phone:520-777-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDO79261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80022385OtherBLUE CROSS BLUE SHIELD
IL212325Medicare PIN
IL80022385OtherBLUE CROSS BLUE SHIELD