Provider Demographics
NPI:1235545419
Name:LAKE GENEVA DENTAL CARE, LLC
Entity Type:Organization
Organization Name:LAKE GENEVA DENTAL CARE, LLC
Other - Org Name:MILTON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
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 1:333 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2641
Mailing Address - Country:US
Mailing Address - Phone:630-833-5110
Mailing Address - Fax:630-833-0458
Practice Address - Street 1:311 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WI
Practice Address - Zip Code:53563-1538
Practice Address - Country:US
Practice Address - Phone:608-868-4462
Practice Address - Fax:608-868-9725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190148581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty