KRYSTLE GRANDBERRY WIDEN DMD Dentist License verification

Business Entity

ACTIVE

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****40

License Status

ACTIVE

Business

Title

DMD

First Name

KRYSTLE

Middle

GRANDBERRY

Last Name

WIDEN

Business Name

KRYSTLE GRANDBERRY WIDEN DMD

Original Issue Date

06/03/2022

Effective Date

07/01/2024

Expiration Date

09/30/2027

City

CHICAGO

State

Zip

60657

County

COOK

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

07/01/2024