Provider Demographics
NPI:1558072827
Name:BORYSIEWSKI, MARY (RDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BORYSIEWSKI
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3169
Mailing Address - Country:US
Mailing Address - Phone:313-207-3011
Mailing Address - Fax:
Practice Address - Street 1:2157 OAK ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-5315
Practice Address - Country:US
Practice Address - Phone:734-285-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011511124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist