Provider Demographics
NPI:1255190955
Name:KRYSTLE GRANDBERRY DMD PLLC
Entity type:Organization
Organization Name:KRYSTLE GRANDBERRY DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:GRANDBERRY
Authorized Official - Last Name:WIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:810-265-3237
Mailing Address - Street 1:2307 W MELROSE ST UNIT F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 305
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5084
Practice Address - Country:US
Practice Address - Phone:810-265-3237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental