Provider Demographics
NPI:1306476817
Name:GROSHEK, DWIGHT DENNIS
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:DENNIS
Last Name:GROSHEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 SUNSET LAKE RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST JUNCTION
Mailing Address - State:WI
Mailing Address - Zip Code:54407-8927
Mailing Address - Country:US
Mailing Address - Phone:715-572-3064
Mailing Address - Fax:
Practice Address - Street 1:1744 SUNSET LAKE RD
Practice Address - Street 2:
Practice Address - City:AMHERST JUNCTION
Practice Address - State:WI
Practice Address - Zip Code:54407-8927
Practice Address - Country:US
Practice Address - Phone:715-572-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12700390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program