Provider Demographics
NPI:1467537902
Name:GROVICH, RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:GROVICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 MAIN STREET
Mailing Address - Street 2:BOX 994
Mailing Address - City:CONYNGHAM
Mailing Address - State:PA
Mailing Address - Zip Code:18219-0994
Mailing Address - Country:US
Mailing Address - Phone:570-788-3963
Mailing Address - Fax:
Practice Address - Street 1:314 MAIN STREET
Practice Address - Street 2:BOX 994
Practice Address - City:CONYNGHAM
Practice Address - State:PA
Practice Address - Zip Code:18219-0994
Practice Address - Country:US
Practice Address - Phone:570-788-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019074L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist