Healthcare Provider Details

I. General information

NPI: 1104638451
Provider Name (Legal Business Name): GRAY FACIAL PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 02/09/2025
Certification Date: 02/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2593 N BIRD ST
BOISE ID
83704-5649
US

IV. Provider business mailing address

2593 N BIRD ST
BOISE ID
83704-5649
US

V. Phone/Fax

Practice location:
  • Phone: 208-631-6990
  • Fax:
Mailing address:
  • Phone: 208-631-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALAN JAMES GRAY
Title or Position: FACIAL PLASTIC SURGEON
Credential: MD
Phone: 208-631-6990