Provider Demographics
NPI:1366598302
Name:GROSSER, ANDRE (DDS)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:GROSSER
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 1:719 W NYACK RD
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-2240
Mailing Address - Country:US
Mailing Address - Phone:845-358-6888
Mailing Address - Fax:845-358-1642
Practice Address - Street 1:719 W NYACK RD
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-2240
Practice Address - Country:US
Practice Address - Phone:845-358-6888
Practice Address - Fax:845-358-1642
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04285911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01505040Medicaid