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General NPI Number Information
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NPI Number | 1043582869
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Entity Type | Organization
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Legal Business Name | GREAT LAKES DENTAL, LLC
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Dates
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Enumeration Date | 02/09/2012
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Last Update Date | 02/09/2012
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Provider Practice Location Address
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Address Line | W188N11927 MAPLE RD SUITE 12
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City | GERMANTOWN
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State | WI
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Zip | 53022-6328
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Country | US
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Telephone | 262-509-5755
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Fax | 262-565-2420
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Provider Business Mailing Address
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Address Line | W188N11927 MAPLE RD SUITE 12
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City | GERMANTOWN
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State | WI
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Zip | 53022-6328
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Country | US
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Telephone | 262-509-5755
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Fax | 262-565-2420
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT J GRZYBOWSKI
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Credential | DDS
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Telephone | 262-509-5755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4018
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License Number State | WI
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