Provider Demographics
NPI:1992873780
Name:GRAYLING DENTAL PC
Entity type:Organization
Organization Name:GRAYLING DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:REX
Authorized Official - Last Name:MORIARITY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-348-4521
Mailing Address - Street 1:BOX 606 604 GALEN STREET
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738
Mailing Address - Country:US
Mailing Address - Phone:989-348-4521
Mailing Address - Fax:989-344-2322
Practice Address - Street 1:604 GALEN STREET
Practice Address - Street 2:GRAYLING DENTAL PC
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738
Practice Address - Country:US
Practice Address - Phone:989-348-4521
Practice Address - Fax:989-344-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010 13182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty