MEDICARE: DR. RICHARD GROVICH DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS019074L	PA

General Provider Information

NPI Number	:	1467537902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD GROVICH DMD

Provider Business Mailing Address
First Line	:	314 MAIN STREET
Second Line	:	BOX 994
City	:	CONYNGHAM
State	:	PA
Zip	:	18219-0994
Country	:	US
Telephone Number	:	570-788-3963
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 MAIN STREET
Second Line	:	BOX 994
City	:	CONYNGHAM
State	:	PA
Zip	:	18219-0994
Country	:	US
Telephone Number	:	570-788-3963
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/08/2007

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