Provider Demographics
NPI:1255960399
Name:TRUMBLE, GRADEN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:GRADEN
Middle Name:
Last Name:TRUMBLE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 E TETON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-6237
Mailing Address - Country:US
Mailing Address - Phone:307-871-5413
Mailing Address - Fax:
Practice Address - Street 1:2029 VALLEYGATE DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3772
Practice Address - Country:US
Practice Address - Phone:910-885-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15041223G0001X
NC121571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1504OtherWYOMING DENTAL LICENSE
NC12157OtherNORTH CAROLINA DENTAL LICENSE