Provider Demographics
NPI:1194932855
Name:GRAYSON, WALTER M JR (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:M
Last Name:GRAYSON
Suffix:JR
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 1:2027 SPRINGVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3640 CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4418
Practice Address - Country:US
Practice Address - Phone:770-938-0232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1881323OtherUNITED CONCORDIA ID