Healthcare Provider Details

I. General information

NPI: 1326473927
Provider Name (Legal Business Name): LAKE GENEVA DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 E HUEBBE PKWY
BELOIT WI
53511-1714
US

IV. Provider business mailing address

333 W 1ST ST
ELMHURST IL
60126-2641
US

V. Phone/Fax

Practice location:
  • Phone: 608-362-0672
  • Fax: 608-362-4960
Mailing address:
  • Phone: 630-833-5110
  • Fax: 630-833-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019014858
License Number StateIL

VIII. Authorized Official

Name: DR. LAWRENCE GROH
Title or Position: OWNER/PRESIDENT
Credential: DDS
Phone: 630-833-5110