Provider Demographics
NPI:1134193147
Name:GROSSMAN, THEODORE (DMD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 505
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 N UNIVERSITY DR
Practice Address - Street 2:SUITE 505
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6332
Practice Address - Country:US
Practice Address - Phone:954-748-8005
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN068181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery