Healthcare Provider Details

I. General information

NPI: 1912456401
Provider Name (Legal Business Name): GRYSKWICZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 YORK ST
KENNEBUNK ME
04043-7157
US

IV. Provider business mailing address

54 YORK ST
KENNEBUNK ME
04043-7157
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SHANNON M. GRYSKWICZ
Title or Position: OWNER/DENTURIST
Credential: LD
Phone: 207-985-0210