Provider Demographics
NPI:1801317375
Name:NICK GROTE FAMILY DENTAL PA
Entity type:Organization
Organization Name:NICK GROTE FAMILY DENTAL PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-806-6556
Mailing Address - Street 1:611 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5159
Mailing Address - Country:US
Mailing Address - Phone:479-474-2701
Mailing Address - Fax:479-474-3977
Practice Address - Street 1:611 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5159
Practice Address - Country:US
Practice Address - Phone:479-474-2701
Practice Address - Fax:479-474-2701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICK GROTE FAMILY DENTAL PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR38811223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200268608Medicaid
AR201489631Medicaid