Provider Demographics
NPI:1962850701
Name:GROSKOPF, KELLY GRUETZMACHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:GRUETZMACHER
Last Name:GROSKOPF
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:GRUETZMACHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1951 COMMERCE PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3139
Mailing Address - Country:US
Mailing Address - Phone:920-563-4415
Mailing Address - Fax:
Practice Address - Street 1:W381N8165 ROLLING RIVER CIR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-8950
Practice Address - Country:US
Practice Address - Phone:715-459-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001308-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice