Provider Demographics
NPI:1295933430
Name:THE GROVE FAMILY DENTAL AND TMJ CLINIC, LLC
Entity type:Organization
Organization Name:THE GROVE FAMILY DENTAL AND TMJ CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GERNETZKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-882-4441
Mailing Address - Street 1:109 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1319
Mailing Address - Country:US
Mailing Address - Phone:608-882-4441
Mailing Address - Fax:
Practice Address - Street 1:109 S MADISON ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1319
Practice Address - Country:US
Practice Address - Phone:608-882-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty