Healthcare Provider Details

I. General information

NPI: 1700952561
Provider Name (Legal Business Name): WILLIAM GRZELAK D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 AUBURN ST
ROCKFORD IL
61103-4679
US

IV. Provider business mailing address

6698 MINDY
ROCKFORD IL
61107
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-2008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: