Provider Demographics
NPI:1073294922
Name:MUNN, GRAYSON (DMD)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:MUNN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2599 NE YELLOWPINE RD
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-9215
Mailing Address - Country:US
Mailing Address - Phone:541-704-8356
Mailing Address - Fax:
Practice Address - Street 1:257 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1910
Practice Address - Country:US
Practice Address - Phone:541-837-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11866122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist