Provider Demographics
NPI:1114489101
Name:GRAYSON, MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GRAYSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-4103
Mailing Address - Fax:585-922-4495
Practice Address - Street 1:1455 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2006
Practice Address - Country:US
Practice Address - Phone:585-922-4103
Practice Address - Fax:585-922-4495
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061171204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery