Provider Demographics
NPI:1659107357
Name:THE GROVE DENTAL GP
Entity type:Organization
Organization Name:THE GROVE DENTAL GP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHASEL
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:BRATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-643-6772
Mailing Address - Street 1:PO BOX 1541
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0360
Mailing Address - Country:US
Mailing Address - Phone:541-492-1687
Mailing Address - Fax:541-418-4311
Practice Address - Street 1:1235 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1286
Practice Address - Country:US
Practice Address - Phone:541-492-1687
Practice Address - Fax:541-418-4311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental