MEDICARE: S GRITSIV DMD PC

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	1223G0001X	General Practice Dentistry	DN013149	GA

General Provider Information

NPI Number	:	1699889857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S GRITSIV DMD PC

Provider Business Mailing Address
First Line	:	PO BOX 329
Second Line	:
City	:	OAKWOOD
State	:	GA
Zip	:	30566-0006
Country	:	US
Telephone Number	:	770-534-4292
Fax Number	:

Provider Business Practice Location Address
First Line	:	4328 MUNDY MILL RD
Second Line	:
City	:	OAKWOOD
State	:	GA
Zip	:	30566-2518
Country	:	US
Telephone Number	:	770-534-4292
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SERGEY GRITSIV
Credential	:	DMD
Telephone Number	:	770-534-4292

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	08/22/2020

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