Provider Demographics
NPI:1487736112
Name:GRZANICH, DEREK P (DDS)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:P
Last Name:GRZANICH
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 1:5518 W BROOKMERE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:IL
Mailing Address - Zip Code:61528-9407
Mailing Address - Country:US
Mailing Address - Phone:309-683-2877
Mailing Address - Fax:
Practice Address - Street 1:9016 N ALLEN RD
Practice Address - Street 2:SUITE B
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1513
Practice Address - Country:US
Practice Address - Phone:309-690-4500
Practice Address - Fax:309-690-4500
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190267241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice