Healthcare Provider Details

I. General information

NPI: 1457555823
Provider Name (Legal Business Name): DEREK FLOYD GRYTZELIUS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13750 19 MILE RD
STERLING HEIGHTS MI
48313-2702
US

IV. Provider business mailing address

13750 19 MILE RD
STERLING HEIGHTS MI
48313-2702
US

V. Phone/Fax

Practice location:
  • Phone: 586-247-0010
  • Fax: 586-247-4333
Mailing address:
  • Phone: 586-247-0010
  • Fax: 586-247-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18970
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: