Healthcare Provider Details

I. General information

NPI: 1538127758
Provider Name (Legal Business Name): PHILIP M GROSNICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N 2ND ST
WATERTOWN WI
53094-3713
US

IV. Provider business mailing address

319 N 2ND ST
WATERTOWN WI
53094-3713
US

V. Phone/Fax

Practice location:
  • Phone: 920-261-2828
  • Fax:
Mailing address:
  • Phone: 920-261-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2831-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: