Provider Demographics
NPI:1487343570
Name:GRUTZ, CAL (DMD)
Entity type:Individual
Prefix:
First Name:CAL
Middle Name:
Last Name:GRUTZ
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 1:1127 ROCK CUT RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53811-9719
Mailing Address - Country:US
Mailing Address - Phone:563-513-9612
Mailing Address - Fax:
Practice Address - Street 1:303 S OSAGE AVE
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:MO
Practice Address - Zip Code:65081-8470
Practice Address - Country:US
Practice Address - Phone:563-513-9612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101200000X, 390200000X
MO20230244411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program