MEDICARE: NINA GRAY, DMD, INC.

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	48513	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G92749-01	OTHER	CA	DENTI-CAL ID

General Provider Information

NPI Number	:	1235279423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NINA GRAY, DMD, INC.

Provider Business Mailing Address
First Line	:	19534 VENTURA BLVD
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-2917
Country	:	US
Telephone Number	:	818-881-2333
Fax Number	:	818-881-2351

Provider Business Practice Location Address
First Line	:	19534 VENTURA BLVD
Second Line	:
City	:	TARZANA
State	:	CA
Zip	:	91356-2917
Country	:	US
Telephone Number	:	818-881-2333
Fax Number	:	818-881-2351

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. NINA MOGHADDAM GRAY
Credential	:	DMD
Telephone Number	:	818-881-2333

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	08/22/2020

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