Provider Demographics
NPI:1659481240
Name:GRAYBILL, ROBERT VAN (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VAN
Last Name:GRAYBILL
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 1:319 S GLENWOOD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801
Mailing Address - Country:US
Mailing Address - Phone:479-968-1334
Mailing Address - Fax:479-968-8912
Practice Address - Street 1:319 S GLENWOOD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-1334
Practice Address - Fax:479-968-8912
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR351223S0112X
AR22071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery