Healthcare Provider Details

I. General information

NPI: 1821154857
Provider Name (Legal Business Name): MATTHEW J GRYZLO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 SPRINGFIELD DR SUITE 100
BLOOMINGDALE IL
60108
US

IV. Provider business mailing address

290 SPRINGFIELD DR SUITE 100
BLOOMINGDALE IL
60108
US

V. Phone/Fax

Practice location:
  • Phone: 630-529-0027
  • Fax: 630-529-0068
Mailing address:
  • Phone: 630-529-0027
  • Fax: 630-529-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19A13829
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: