MEDICARE: DR. TIMOTHY ROSS GRAY DDS

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	DE00006253	WA

General Provider Information

NPI Number	:	1588662118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY ROSS GRAY DDS

Provider Business Mailing Address
First Line	:	23625 140TH AVE SE
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98042-3805
Country	:	US
Telephone Number	:	253-854-9890
Fax Number	:

Provider Business Practice Location Address
First Line	:	13106 SE 240TH ST
Second Line	:	SUITE 102
City	:	KENT
State	:	WA
Zip	:	98031-9210
Country	:	US
Telephone Number	:	253-854-9890
Fax Number	:	253-852-0585

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/08/2007

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