Provider Demographics
NPI:1093049306
Name:SHAVER, GRADY D (DMD)
Entity Type:Individual
Prefix:MR
First Name:GRADY
Middle Name:D
Last Name:SHAVER
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0160
Mailing Address - Country:US
Mailing Address - Phone:541-966-9830
Mailing Address - Fax:541-278-7590
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-0160
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-278-7590
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60114016122300000X
ORD9825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500653068Medicaid