Provider Demographics
NPI:1346356516
Name:GRIDLEY, MICHAEL M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:GRIDLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 OSWEGO ST
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-457-4262
Mailing Address - Fax:315-457-4262
Practice Address - Street 1:725 OSWEGO ST
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-457-4262
Practice Address - Fax:315-457-4262
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist