Provider Demographics
NPI:1972616712
Name:GROTHE, CHARLES RAYMOND KONDO (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RAYMOND KONDO
Last Name:GROTHE
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 1:401 E RANDOLPH
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701
Mailing Address - Country:US
Mailing Address - Phone:580-233-4561
Mailing Address - Fax:580-233-4561
Practice Address - Street 1:401 E RANDOLPH
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701
Practice Address - Country:US
Practice Address - Phone:580-233-4561
Practice Address - Fax:580-233-4561
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist