Provider Demographics
NPI:1477631638
Name:GRUEZKE, FREDERICK HERMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:HERMAN
Last Name:GRUEZKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 LAPALCO BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058
Mailing Address - Country:US
Mailing Address - Phone:504-361-3697
Mailing Address - Fax:504-362-3662
Practice Address - Street 1:1705 LAPALCO BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058
Practice Address - Country:US
Practice Address - Phone:504-361-3697
Practice Address - Fax:504-362-3662
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist