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General NPI Number Information
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NPI Number | 1235754516
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Entity Type | Individual
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Provider Name | MALORY JO GROEN DMD
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Gender | Female
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Dates
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Enumeration Date | 06/11/2020
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Last Update Date | 06/11/2020
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Provider Practice Location Address
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Address Line | 1714 N RANDALL AVE
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City | JANESVILLE
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State | WI
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Zip | 53545-0900
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Country | US
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Telephone | 608-756-1229
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Fax |
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Provider Business Mailing Address
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Address Line | 1883 FAYS LN
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City | SUGAR GROVE
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State | IL
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Zip | 60554-9772
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Country | US
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Telephone | 630-373-6543
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1002310-15
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License Number State | WI
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