Provider Demographics
NPI:1518453570
Name:GREYSLAK DENTAL LLC
Entity Type:Organization
Organization Name:GREYSLAK DENTAL LLC
Other - Org Name:CORVALLIS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREYSLAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-830-3812
Mailing Address - Street 1:3553 SW PAR PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1160
Mailing Address - Country:US
Mailing Address - Phone:503-830-3812
Mailing Address - Fax:
Practice Address - Street 1:2318 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3925
Practice Address - Country:US
Practice Address - Phone:541-754-6116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD101271223G0001X
ORD101041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1417358961OtherJASON GREYSLAK