Provider Demographics
NPI:1326148974
Name:GRESCZYK, NICOLE A (CRDA/RDA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:GRESCZYK
Suffix:
Gender:F
Credentials:CRDA/RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 FROST AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-4611
Mailing Address - Country:US
Mailing Address - Phone:651-251-3859
Mailing Address - Fax:
Practice Address - Street 1:1789 WOODLANE DR
Practice Address - Street 2:#D
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3910
Practice Address - Country:US
Practice Address - Phone:651-738-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant