Provider Demographics
NPI:1184760480
Name:GROSHAN, GREGORY JOSEPH (DMD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOSEPH
Last Name:GROSHAN
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 1:4131 UNIVERSITY BLVD S
Mailing Address - Street 2:BLDG #1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4326
Mailing Address - Country:US
Mailing Address - Phone:904-737-3617
Mailing Address - Fax:904-737-8326
Practice Address - Street 1:3007 HARTLEY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6201
Practice Address - Country:US
Practice Address - Phone:904-737-3617
Practice Address - Fax:904-737-8326
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00133371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL69329AMedicare PIN