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General NPI Number Information
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NPI Number | 1740336114
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Entity Type | Organization
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Legal Business Name | DR. MARY GROTE
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 301 S ROOSEVELT DR SUITE A
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City | BEAVER DAM
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State | WI
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Zip | 53916-2439
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Country | US
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Telephone | 920-887-8423
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Fax | 920-887-8471
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Provider Business Mailing Address
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Address Line | 301 S ROOSEVELT DR SUITE A
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City | BEAVER DAM
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State | WI
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Zip | 53916-2439
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Country | US
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Telephone | 920-887-8423
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Fax | 920-887-8471
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARY GROTE
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Credential | DDS
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Telephone | 920-887-8423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 2582-015
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License Number State | WI
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