Provider Demographics
NPI:1700936069
Name:GROSS, REBECCA BURACK
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:BURACK
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 N NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2959
Mailing Address - Country:US
Mailing Address - Phone:704-865-6425
Mailing Address - Fax:704-865-2568
Practice Address - Street 1:1146 N NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2959
Practice Address - Country:US
Practice Address - Phone:704-865-6425
Practice Address - Fax:704-865-2568
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCN61971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry