Healthcare Provider Details

I. General information

NPI: 1780001735
Provider Name (Legal Business Name): SHANNON GRYSKWICZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON GRYSKWICZ LD

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 YORK ST
KENNEBUNK ME
04043-7157
US

IV. Provider business mailing address

PO BOX 354
STANDISH ME
04084-0354
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-0210
  • Fax: 207-985-8068
Mailing address:
  • Phone: 207-985-0210
  • Fax: 207-642-6815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number5007
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: