Provider Demographics
NPI:1154821924
Name:GROSS, MICHAEL (DMD, MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD # CS3.104
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9109
Mailing Address - Country:US
Mailing Address - Phone:214-645-3979
Mailing Address - Fax:
Practice Address - Street 1:16410 SMOKEY POINT BLVD STE 103
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8415
Practice Address - Country:US
Practice Address - Phone:360-658-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE612135961223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery