Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 061171 | NY |
NPI | 1114489101 |
---|---|
Provider Name | Michelle Grayson |
First Address | Rochester, NY 14617-5504 |
Second Address | Rochester, NY 14621-2006 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/04/2019 |
Last Update Date | 24/09/2020 |