Healthcare Provider Details

I. General information

NPI: 1679675987
Provider Name (Legal Business Name): DR. RICHARD J. GRZYBOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 WEST BURLEIGH STREET
WAUWATOSA WI
53222
US

IV. Provider business mailing address

3725 STONEBROOK COURT
BROOKFIELD WI
53005
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-2345
  • Fax:
Mailing address:
  • Phone: 262-790-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3572
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: