Provider Demographics
NPI:1225107956
Name:GROEN, MICHAEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:GROEN
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 1:506 GROVER ST
Mailing Address - Street 2:#108
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1960
Mailing Address - Country:US
Mailing Address - Phone:360-354-6036
Mailing Address - Fax:360-354-5586
Practice Address - Street 1:506 GROVER ST
Practice Address - Street 2:#108
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1960
Practice Address - Country:US
Practice Address - Phone:360-354-6036
Practice Address - Fax:360-354-5586
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5575122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5078001Medicaid