Provider Demographics
NPI:1700807336
Name:GRBACH, BRUCE DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DANIEL
Last Name:GRBACH
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 1:9203 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6477
Mailing Address - Country:US
Mailing Address - Phone:440-255-3165
Mailing Address - Fax:440-255-6757
Practice Address - Street 1:9203 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6477
Practice Address - Country:US
Practice Address - Phone:440-255-3165
Practice Address - Fax:440-255-6757
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0177891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice