Provider Demographics
NPI:1508921420
Name:GRISAR, DAVID ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
Last Name:GRISAR
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 1:1515 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-1962
Mailing Address - Country:US
Mailing Address - Phone:262-377-4130
Mailing Address - Fax:
Practice Address - Street 1:1515 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-1962
Practice Address - Country:US
Practice Address - Phone:262-377-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5018-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist