Provider Demographics
NPI:1780001735
Name:GRYSKWICZ, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GRYSKWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:GRYSKWICZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LD
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-0354
Mailing Address - Country:US
Mailing Address - Phone:207-985-0210
Mailing Address - Fax:207-642-6815
Practice Address - Street 1:54 YORK ST
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-7157
Practice Address - Country:US
Practice Address - Phone:207-985-0210
Practice Address - Fax:207-985-8068
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME5007122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist