=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679746614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOSEPH DENTAL ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2008
-----------------------------------------------------
Last Update Date | 09/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4912 W ST JOE HWY
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48917-4090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-886-1100
-----------------------------------------------------
Fax | 517-327-1071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4912 W ST JOE HWY
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48917-4090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-886-1100
-----------------------------------------------------
Fax | 517-327-1071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. GARY THOMAS ORYSZCZAK
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 517-886-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 11335
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------