Healthcare Provider Details

I. General information

NPI: 1083732101
Provider Name (Legal Business Name): LAKE GENEVA DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 BROAD ST
LAKE GENEVA WI
53147-1420
US

IV. Provider business mailing address

580 BROAD ST
LAKE GENEVA WI
53147-1420
US

V. Phone/Fax

Practice location:
  • Phone: 262-248-2773
  • Fax: 262-248-3895
Mailing address:
  • Phone: 262-248-2773
  • Fax: 262-248-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5788
License Number StateWI

VIII. Authorized Official

Name: DR. LAWRENCE GROH
Title or Position: OWNER
Credential: D.D.S.
Phone: 630-833-5110