Provider Demographics
NPI:1518944529
Name:TWOHIG, GRADY M (DDS)
Entity Type:Individual
Prefix:
First Name:GRADY
Middle Name:M
Last Name:TWOHIG
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 1:211 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5359
Mailing Address - Country:US
Mailing Address - Phone:920-921-8565
Mailing Address - Fax:920-921-0121
Practice Address - Street 1:211 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-5359
Practice Address - Country:US
Practice Address - Phone:920-921-8565
Practice Address - Fax:920-921-0121
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58720151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice