Provider Demographics
NPI:1992853204
Name:GRONBACH, KEITH ROGER (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ROGER
Last Name:GRONBACH
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 1:3799 MT DIABLO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3538
Mailing Address - Country:US
Mailing Address - Phone:925-283-4050
Mailing Address - Fax:925-283-5340
Practice Address - Street 1:3799 MT DIABLO BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3538
Practice Address - Country:US
Practice Address - Phone:925-283-4050
Practice Address - Fax:925-283-5340
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
94-1723333OtherFEDERAL TIN
CAYYY49754YMedicare UPIN