Provider Demographics
NPI:1154737906
Name:GRONSTEN, CODY EUGENE
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:EUGENE
Last Name:GRONSTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-6440
Mailing Address - Country:US
Mailing Address - Phone:605-996-1316
Mailing Address - Fax:605-996-6629
Practice Address - Street 1:240 E 23RD ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-6440
Practice Address - Country:US
Practice Address - Phone:605-996-1316
Practice Address - Fax:605-996-6629
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist