Provider Demographics
NPI:1124690441
Name:GRIGORYAN, ARTYOM G (DDS)
Entity type:Individual
Prefix:
First Name:ARTYOM
Middle Name:G
Last Name:GRIGORYAN
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 1:2505 W MEQUON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3166
Mailing Address - Country:US
Mailing Address - Phone:262-242-1180
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002691122400000X
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122400000XDental ProvidersDenturist