MEDICARE: GRAYSON MCREYNOLDS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4621	AR

General Provider Information

NPI Number	:	1962133561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRAYSON MCREYNOLDS DDS

Provider Business Mailing Address
First Line	:	1607 MAIN ST
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-4735
Country	:	US
Telephone Number	:	479-474-7076
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 MAIN ST
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-4735
Country	:	US
Telephone Number	:	479-474-7076
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2022
Last Update Date	:	06/23/2022

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