Provider Demographics
NPI:1144249970
Name:GROSSMAN, DAVID FOX (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:FOX
Last Name:GROSSMAN
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 1:208 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3916
Mailing Address - Country:US
Mailing Address - Phone:843-355-7606
Mailing Address - Fax:843-355-7606
Practice Address - Street 1:208 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3916
Practice Address - Country:US
Practice Address - Phone:843-355-7606
Practice Address - Fax:843-355-7606
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ19329Medicaid