Provider Demographics
NPI:1790820538
Name:GRADECKI, LAURA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:GRADECKI
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 1:1727 W EL RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5637
Mailing Address - Country:US
Mailing Address - Phone:262-241-0978
Mailing Address - Fax:
Practice Address - Street 1:10555 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5582
Practice Address - Country:US
Practice Address - Phone:262-241-4460
Practice Address - Fax:262-241-4486
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3633-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice