Provider Demographics
NPI:1750541918
Name:GROSSMAN, TRACY JOHN (DDS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JOHN
Last Name:GROSSMAN
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 1:1029 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2398
Mailing Address - Country:US
Mailing Address - Phone:507-376-9797
Mailing Address - Fax:
Practice Address - Street 1:1029 3RD AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2398
Practice Address - Country:US
Practice Address - Phone:507-376-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice