Provider Demographics
NPI:1962801084
Name:GREYSLAK, ROSE (DMD)
Entity type:Individual
Prefix:DR
First Name:ROSE
Middle Name:
Last Name:GREYSLAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:442 SW UMATILLA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-7039
Mailing Address - Country:US
Mailing Address - Phone:541-504-3900
Mailing Address - Fax:541-504-3907
Practice Address - Street 1:300 TATONE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OR
Practice Address - Zip Code:97818-9999
Practice Address - Country:US
Practice Address - Phone:888-468-0022
Practice Address - Fax:541-504-3907
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10104122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist