Provider Demographics
NPI:1356829758
Name:GRIEBENOW, LAUREN KEIKO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:KEIKO
Last Name:GRIEBENOW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:KEIKO
Other - Last Name:GROOTHUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:8855 W 300 S
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9529
Mailing Address - Country:US
Mailing Address - Phone:765-513-1922
Mailing Address - Fax:
Practice Address - Street 1:5111 CLINTON DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-7136
Practice Address - Country:US
Practice Address - Phone:765-453-4369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013001A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice