Provider Demographics
NPI:1962183988
Name:GROGAN, CAITLIN NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:NICOLE
Last Name:GROGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 EL CAJON BLVD APT 711
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3884
Mailing Address - Country:US
Mailing Address - Phone:202-412-5287
Mailing Address - Fax:
Practice Address - Street 1:3767 AVOCADO BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7301
Practice Address - Country:US
Practice Address - Phone:619-729-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist