Provider Demographics
NPI:1083732101
Name:LAKE GENEVA DENTAL CARE LLC
Entity Type:Organization
Organization Name:LAKE GENEVA DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-833-5110
Mailing Address - Street 1:580 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1420
Mailing Address - Country:US
Mailing Address - Phone:262-248-2773
Mailing Address - Fax:262-248-3895
Practice Address - Street 1:580 BROAD ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1420
Practice Address - Country:US
Practice Address - Phone:262-248-2773
Practice Address - Fax:262-248-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty