MEDICARE: DR. GARY ROBERT GRISWOLD D.D.S.

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	122300000X	Dentist	7975	MD

General Provider Information

NPI Number	:	1598974362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY ROBERT GRISWOLD D.D.S.

Provider Business Mailing Address
First Line	:	16804 CAMBERFORD ST.
Second Line	:
City	:	ROCKVILLE
State	:	MD
Zip	:	20855
Country	:	US
Telephone Number	:	301-926-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	19620 CLUB HOUSE RD STE A
Second Line	:
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20886-3056
Country	:	US
Telephone Number	:	301-926-1900
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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