MEDICARE: STACIE GRISWOLD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	6717-16	WI

General Provider Information

NPI Number	:	1235088816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE GRISWOLD

Provider Business Mailing Address
First Line	:	W319N825 COBBLESTONE CT
Second Line	:
City	:	DELAFIELD
State	:	WI
Zip	:	53018-2643
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 S 1ST ST # 276
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53204-2405
Country	:	US
Telephone Number	:	407-375-3003
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2026
Last Update Date	:	01/26/2026

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Directions to “ STACIE GRISWOLD ” Practice Location

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