Provider Demographics
NPI:1194563262
Name:GROVE, CHANDLER
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:GROVE
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 1:2131 STRASBURG CT
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5218
Mailing Address - Country:US
Mailing Address - Phone:404-637-6723
Mailing Address - Fax:
Practice Address - Street 1:1360 CADUCEUS WAY
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7300
Practice Address - Country:US
Practice Address - Phone:706-543-3629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1234761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice