Provider Demographics
NPI:1215662788
Name:GROLL, CODY SHAWN (DDS)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:SHAWN
Last Name:GROLL
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:PO BOX 1808
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3011 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-2546
Practice Address - Country:US
Practice Address - Phone:202-319-8736
Practice Address - Fax:620-231-5062
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12891810-9922122300000X
KS61967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist