MEDICARE: DR. STEPHEN WRAY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	NM1630	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	826091	OTHER	NM	UNITED CONCORDIA
2	8957	OTHER	NM	BLUE CROSS BLUE SHEILD NU

General Provider Information

NPI Number	:	1134125222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN WRAY D.D.S.

Provider Business Mailing Address
First Line	:	1830 JUAN TABO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3302
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1830 JUAN TABO BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3302
Country	:	US
Telephone Number	:	505-294-1401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	08/29/2007

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Directions to “ DR. STEPHEN WRAY D.D.S.” Practice Location

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