Provider Demographics
NPI:1356028898
Name:GROVE, RYAN (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GROVE
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 1:1945 ALLISON ST
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-4810
Mailing Address - Country:US
Mailing Address - Phone:402-740-2979
Mailing Address - Fax:
Practice Address - Street 1:401 OAK ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-2521
Practice Address - Country:US
Practice Address - Phone:940-549-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE79251223G0001X
TX40360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice