Provider Demographics
NPI:1265694657
Name:GROVEWAY DENTAL ASSOCIATES
Entity type:Organization
Organization Name:GROVEWAY DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SELMA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GUTTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-641-1118
Mailing Address - Street 1:4501 GROVEWAY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-1122
Mailing Address - Country:US
Mailing Address - Phone:713-641-1118
Mailing Address - Fax:713-640-2221
Practice Address - Street 1:4501 GROVEWAY DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-1122
Practice Address - Country:US
Practice Address - Phone:713-641-1118
Practice Address - Fax:713-640-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009788301Medicaid