MEDICARE: JOHN K GROTHE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN014448	FL

General Provider Information

NPI Number	:	1851412613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN K GROTHE DMD

Provider Business Mailing Address
First Line	:	8454 NORTHCLIFFE BLVD
Second Line	:	LAKESIDE FAMILY DENTAL CARE
City	:	SPRING HILL
State	:	FL
Zip	:	34606
Country	:	US
Telephone Number	:	352-686-1122
Fax Number	:	352-688-8693

Provider Business Practice Location Address
First Line	:	8454 NORTHCLIFFE BLVD
Second Line	:	LAKESIDE FAMILY DENTAL CARE
City	:	SPRING HILL
State	:	FL
Zip	:	34606-1140
Country	:	US
Telephone Number	:	352-686-1122
Fax Number	:	352-688-8693

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/08/2007

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