MEDICARE: GRAYSON GAYNOR COLE D.D.S.

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	1223P0106X	Oral and Maxillofacial Pathology Dentistry	019034056	IL
2	1223P0106X	Oral and Maxillofacial Pathology Dentistry	30.27435	OH

General Provider Information

NPI Number	:	1821614165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRAYSON GAYNOR COLE D.D.S.

Provider Business Mailing Address
First Line	:	11100 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-1716
Country	:	US
Telephone Number	:	216-844-8447
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44106-1716
Country	:	US
Telephone Number	:	216-844-8447
Fax Number	:

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

Provider Enumeration Date	:	06/23/2020
Last Update Date	:	06/11/2024

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