Healthcare Provider Details

I. General information

NPI: 1093049306
Provider Name (Legal Business Name): GRADY D SHAVER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73265 CONFEDERATED WAY
PENDLETON OR
97801-0160
US

IV. Provider business mailing address

PO BOX 160
PENDLETON OR
97801-0160
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-9830
  • Fax: 541-278-7590
Mailing address:
  • Phone: 541-966-9830
  • Fax: 541-278-7590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60114016
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9825
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: