Provider Demographics
NPI:1023115821
Name:GRUNDSTROM, TALVA (D,M,D,)
Entity type:Individual
Prefix:
First Name:TALVA
Middle Name:
Last Name:GRUNDSTROM
Suffix:
Gender:F
Credentials:D,M,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1186
Mailing Address - Country:US
Mailing Address - Phone:573-634-4414
Mailing Address - Fax:573-634-8385
Practice Address - Street 1:2022 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1186
Practice Address - Country:US
Practice Address - Phone:573-634-4414
Practice Address - Fax:573-634-8385
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014579122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist