MEDICARE: DR. SANFORD E. GRUSKIN D.D.S., M.S.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	7571	GA

General Provider Information

NPI Number	:	1639299704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANFORD E. GRUSKIN D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	259 ARROWHEAD BLVD STE A
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30236-1167
Country	:	US
Telephone Number	:	770-471-4196
Fax Number	:	770-477-0505

Provider Business Practice Location Address
First Line	:	259 ARROWHEAD BLVD STE A
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30236-1167
Country	:	US
Telephone Number	:	770-471-4196
Fax Number	:	770-477-0505

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	07/08/2007

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