Provider Demographics
NPI:1083873004
Name:GRUCHALSKI, JON JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:JAMES
Last Name:GRUCHALSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 SOUTH CHURCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151
Mailing Address - Country:US
Mailing Address - Phone:262-784-2449
Mailing Address - Fax:262-784-7873
Practice Address - Street 1:4010 SOUTH CHURCH DRIVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151
Practice Address - Country:US
Practice Address - Phone:262-784-2449
Practice Address - Fax:262-784-7873
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice