Provider Demographics
NPI:1740710052
Name:GROUNDS, ETHAN THOMAS (DMD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:THOMAS
Last Name:GROUNDS
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 1:300 SMALL ST STE D
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-3325
Mailing Address - Country:US
Mailing Address - Phone:618-252-1725
Mailing Address - Fax:
Practice Address - Street 1:300 SMALL ST STE D
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-3325
Practice Address - Country:US
Practice Address - Phone:618-252-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0311821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice