Provider Demographics
NPI:1467297788
Name:SYPAWKA, MARY LISA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
Last Name:SYPAWKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4442
Mailing Address - Country:US
Mailing Address - Phone:252-916-3553
Mailing Address - Fax:
Practice Address - Street 1:906 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:NC
Practice Address - Zip Code:28516-1723
Practice Address - Country:US
Practice Address - Phone:252-254-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist