MEDICARE: DR. BRENT WAYNE GRAY DMD

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	122300000X	Dentist	276161-9922	UT

General Provider Information

NPI Number	:	1699988790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT WAYNE GRAY DMD

Provider Business Mailing Address
First Line	:	1445 N 400 E STE 2
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-7564
Country	:	US
Telephone Number	:	435-752-4136
Fax Number	:	435-752-5177

Provider Business Practice Location Address
First Line	:	1445 N 400 E STE 2
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-7564
Country	:	US
Telephone Number	:	435-752-4136
Fax Number	:	435-752-5177

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	07/08/2007

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