Provider Demographics
NPI:1104893742
Name:GRITSIV, SERGEY VALERIEYVICH (DMD)
Entity type:Individual
Prefix:
First Name:SERGEY
Middle Name:VALERIEYVICH
Last Name:GRITSIV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-0001
Mailing Address - Country:US
Mailing Address - Phone:770-534-4292
Mailing Address - Fax:
Practice Address - Street 1:4038 MUNDY MILL RD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2518
Practice Address - Country:US
Practice Address - Phone:770-534-4292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013149122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist