Provider Demographics
NPI:1891849295
Name:GROSS, MICHAEL L (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:GROSS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SOUTH ROAD
Mailing Address - Street 2:PO BOX 1747
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-1747
Mailing Address - Country:US
Mailing Address - Phone:270-522-3484
Mailing Address - Fax:270-522-4662
Practice Address - Street 1:51 SOUTH ROAD
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-1747
Practice Address - Country:US
Practice Address - Phone:270-522-3484
Practice Address - Fax:270-522-4662
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKENTUCKY52971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60052974Medicaid