Provider Demographics
NPI:1821154857
Name:GRYZLO, MATTHEW J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:GRYZLO
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 1:290 SPRINGFIELD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108
Mailing Address - Country:US
Mailing Address - Phone:630-529-0027
Mailing Address - Fax:630-529-0068
Practice Address - Street 1:290 SPRINGFIELD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108
Practice Address - Country:US
Practice Address - Phone:630-529-0027
Practice Address - Fax:630-529-0068
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A138291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice