Provider Demographics
NPI:1225176035
Name:GRODOVICH, LORRAINE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:LORRAINE
Middle Name:M
Last Name:GRODOVICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 SILAS DEANE HIGHWAY
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-563-3766
Practice Address - Fax:860-721-0160
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice