Basic Information
| Provider Information | |||||||||
| NPI: | 1578511465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSSMAN | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 W. 6TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313144704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127676735 | ||||||||
| FaxNumber: | 9127675425 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 W 6TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313144703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127676735 | ||||||||
| FaxNumber: | 9127675425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 027540 | NY | Y | Dental Providers | Dentist | General Practice |
No ID Information.