Provider Demographics
NPI:1679067375
Name:GROSHART, KENNETH II
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GROSHART
Suffix:II
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 1:6250 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4713
Mailing Address - Country:US
Mailing Address - Phone:901-681-0011
Mailing Address - Fax:901-681-9725
Practice Address - Street 1:6250 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4713
Practice Address - Country:US
Practice Address - Phone:901-681-0011
Practice Address - Fax:901-681-9725
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist