Provider Demographics
NPI:1932115011
Name:GRODNER, JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:GRODNER
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 1:413 E HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2708
Mailing Address - Country:US
Mailing Address - Phone:937-390-3077
Mailing Address - Fax:
Practice Address - Street 1:413 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2708
Practice Address - Country:US
Practice Address - Phone:937-390-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH107461OtherDORAL LOCATOR NUMBER
OH310916628026OtherCARESOURCE-MEDICAID
OH0341446Medicaid