Provider Demographics
NPI:1750151361
Name:THE GROVE DENTISTRY LLC
Entity type:Organization
Organization Name:THE GROVE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:251-275-3822
Mailing Address - Street 1:PO BOX 879
Mailing Address - Street 2:
Mailing Address - City:GROVE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36451-0879
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:297C S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3231
Practice Address - Country:US
Practice Address - Phone:251-275-3822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental