Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 5007 | ME |
NPI | 1780001735 |
---|---|
Provider Name | Shannon Gryskwicz |
First Address | Standish, ME 04084-0354 |
Second Address | Kennebunk, ME 04043-7157 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2014 |
Last Update Date | 12/09/2016 |