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General NPI Number Information
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NPI Number | 1255190955
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Entity Type | Organization
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Legal Business Name | KRYSTLE GRANDBERRY DMD PLLC
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Dates
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Enumeration Date | 03/15/2024
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Last Update Date | 03/15/2024
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Provider Practice Location Address
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Address Line | 2835 N SHEFFIELD AVE STE 305
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City | CHICAGO
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State | IL
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Zip | 60657-5084
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Country | US
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Telephone | 810-265-3237
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Fax |
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Provider Business Mailing Address
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Address Line | 2307 W MELROSE ST UNIT F
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City | CHICAGO
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State | IL
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Zip | 60618-6317
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, OWNER
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Name | DR. KRYSTLE GRANDBERRY WIDEN
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Credential | DMD
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Telephone | 810-265-3237
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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