Provider Demographics
NPI:1225580962
Name:GROSSMAN, JESSE (RDH)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2013
Mailing Address - Country:US
Mailing Address - Phone:208-848-8300
Mailing Address - Fax:208-848-8306
Practice Address - Street 1:844 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2013
Practice Address - Country:US
Practice Address - Phone:208-848-8300
Practice Address - Fax:208-848-8306
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60682830124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist