Healthcare Provider Details

I. General information

NPI: 1134235609
Provider Name (Legal Business Name): BRAY, DMD & YOUNG, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LESTER CT
STATESBORO GA
30458-2118
US

IV. Provider business mailing address

715 NORTHSIDE DR E SUITE 5, PMB 395
STATESBORO GA
30458-4712
US

V. Phone/Fax

Practice location:
  • Phone: 912-489-1386
  • Fax: 912-764-8533
Mailing address:
  • Phone: 912-489-1386
  • Fax: 912-764-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9793
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10099
License Number StateGA

VIII. Authorized Official

Name: DR. CECIL B BRAY III
Title or Position: PRESIDENT
Credential: DMD
Phone: 912-489-1386