Provider Demographics
NPI:1538598164
Name:GROESBECK, LEONA M
Entity type:Individual
Prefix:
First Name:LEONA
Middle Name:M
Last Name:GROESBECK
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 1:1357 OLIVIA CT
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9495
Mailing Address - Country:US
Mailing Address - Phone:360-739-1938
Mailing Address - Fax:
Practice Address - Street 1:5616 3RD AVE
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-8394
Practice Address - Country:US
Practice Address - Phone:360-752-7410
Practice Address - Fax:360-383-0808
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH 00001494124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist