Provider Demographics
NPI:1326473927
Name:LAKE GENEVA DENTAL CARE, LLC
Entity Type:Organization
Organization Name:LAKE GENEVA DENTAL CARE, LLC
Other - Org Name:BELOIT 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 1:1454 E HUEBBE PKWY
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1714
Practice Address - Country:US
Practice Address - Phone:608-362-0672
Practice Address - Fax:608-362-4960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190148581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty