Healthcare Provider Details

I. General information

NPI: 1184772774
Provider Name (Legal Business Name): JOHN I GRAY III PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 E HIGH ST
MT STERLING KY
40353-1267
US

IV. Provider business mailing address

25 E HIGH ST
MT STERLING KY
40353-1267
US

V. Phone/Fax

Practice location:
  • Phone: 859-498-6204
  • Fax: 859-498-6205
Mailing address:
  • Phone: 859-498-6204
  • Fax: 859-498-6205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4210
License Number StateKY

VIII. Authorized Official

Name: DR. JOHN I GRAY III
Title or Position: PRESIDENT
Credential: DMD
Phone: 859-498-6204