Healthcare Provider Details

I. General information

NPI: 1457579344
Provider Name (Legal Business Name): RONALD L GROTHE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 SKYLINE DR SW
ROCHESTER MN
55902-1220
US

IV. Provider business mailing address

973 SKYLINE DR SW
ROCHESTER MN
55902-1220
US

V. Phone/Fax

Practice location:
  • Phone: 507-424-1040
  • Fax:
Mailing address:
  • Phone: 507-424-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9882
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD9882
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: