Provider Demographics
NPI:1750019105
Name:GROELLE, HALEY
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:GROELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2205
Mailing Address - Country:US
Mailing Address - Phone:262-335-0822
Mailing Address - Fax:
Practice Address - Street 1:2115 W WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53059
Practice Address - Country:US
Practice Address - Phone:262-335-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI600005315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist