Provider Demographics
NPI:1073636825
Name:GRABAVOY, GEORGE NICHOLAS
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:NICHOLAS
Last Name:GRABAVOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 N LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3455
Mailing Address - Country:US
Mailing Address - Phone:815-744-4503
Mailing Address - Fax:
Practice Address - Street 1:1106 N LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3455
Practice Address - Country:US
Practice Address - Phone:815-744-4503
Practice Address - Fax:815-744-4047
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist