Basic Information
| Provider Information | |||||||||
| NPI: | 1568183424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRODACK | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | PHDHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 164 THE HIDEOUT | ||||||||
| Address2: | 331 CEDARWOOD TERRACE | ||||||||
| City: | LAKE ARIEL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709096180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | JERMYN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184331121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702300019 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2022 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | PHDH001290 | PA | Y | Dental Providers | Dental Hygienist |
No ID Information.