Provider Demographics
NPI:1174149751
Name:GROELING, JOHNNY MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:MICHAEL
Last Name:GROELING
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 1:650 W 42ND ST APT 1421
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4370
Mailing Address - Country:US
Mailing Address - Phone:631-352-7746
Mailing Address - Fax:
Practice Address - Street 1:1500 SUMMER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5132
Practice Address - Country:US
Practice Address - Phone:203-303-9802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT13037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program