Healthcare Provider Details

I. General information

NPI: 1558072827
Provider Name (Legal Business Name): MARY BORYSIEWSKI RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

803 WINCHESTER AVE
LINCOLN PARK MI
48146-3169
US

V. Phone/Fax

Practice location:
  • Phone: 734-845-3411
  • Fax:
Mailing address:
  • Phone: 313-207-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902011511
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: