Provider Demographics
NPI:1023080256
Name:GRABOW, WAYNE ERWIN (DENTIST DDS)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:ERWIN
Last Name:GRABOW
Suffix:
Gender:M
Credentials:DENTIST DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:21 DS/SGGD-DENTAL CLINIC
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1540
Mailing Address - Country:US
Mailing Address - Phone:719-556-1333
Mailing Address - Fax:866-867-7926
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:21 DS/SGGD-DENTAL CLINIC
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1540
Practice Address - Country:US
Practice Address - Phone:719-556-1333
Practice Address - Fax:866-867-7926
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist