Healthcare Provider Details

I. General information

NPI: 1578001616
Provider Name (Legal Business Name): JESSE R GRAY DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3119 E MISSION BLVD
FAYETTEVILLE AR
72703-6617
US

IV. Provider business mailing address

3119 E MISSION BLVD
FAYETTEVILLE AR
72703-6617
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-4181
  • Fax: 479-521-0442
Mailing address:
  • Phone: 479-521-4181
  • Fax: 479-521-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3427
License Number StateAR

VIII. Authorized Official

Name: DR. JESS R GRAY
Title or Position: OWNER
Credential: DDS
Phone: 479-521-4181