Provider Demographics
NPI:1073548707
Name:GRAYDON, DOUGLAS M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:GRAYDON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:CHICKAMAUGA
Mailing Address - State:GA
Mailing Address - Zip Code:30707-0369
Mailing Address - Country:US
Mailing Address - Phone:706-375-3621
Mailing Address - Fax:706-375-8054
Practice Address - Street 1:107 GORDON ST
Practice Address - Street 2:
Practice Address - City:CHICKAMAUGA
Practice Address - State:GA
Practice Address - Zip Code:30707-1454
Practice Address - Country:US
Practice Address - Phone:706-375-3621
Practice Address - Fax:706-375-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice