Provider Demographics
NPI:1043582869
Name:GREAT LAKES DENTAL, LLC
Entity Type:Organization
Organization Name:GREAT LAKES DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRZYBOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-509-5755
Mailing Address - Street 1:W188N11927 MAPLE RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6328
Mailing Address - Country:US
Mailing Address - Phone:262-509-5755
Mailing Address - Fax:262-565-2420
Practice Address - Street 1:W188N11927 MAPLE RD
Practice Address - Street 2:SUITE 12
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-6328
Practice Address - Country:US
Practice Address - Phone:262-509-5755
Practice Address - Fax:262-565-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty