Provider Demographics
NPI:1629171962
Name:GROTE, MARY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:GROTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SOUTH ROOSEVELT DR.
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2442
Mailing Address - Country:US
Mailing Address - Phone:920-887-8423
Mailing Address - Fax:920-887-8471
Practice Address - Street 1:301 S ROOSEVELT DR
Practice Address - Street 2:SUITE A
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2439
Practice Address - Country:US
Practice Address - Phone:920-887-8423
Practice Address - Fax:920-887-8471
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2582-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62069Medicare UPIN
000078629Medicare ID - Type Unspecified