MEDICARE: CRYSTAL DAWN GRYTE RDH

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	22286	CA

General Provider Information

NPI Number	:	1992974430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL DAWN GRYTE RDH

Provider Business Mailing Address
First Line	:	5790 S ELM AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93706-5813
Country	:	US
Telephone Number	:	559-233-2688
Fax Number	:

Provider Business Practice Location Address
First Line	:	5790 S ELM AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93706-5813
Country	:	US
Telephone Number	:	559-233-2688
Fax Number	:

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

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	02/28/2008

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