Healthcare Provider Details

I. General information

NPI: 1336365956
Provider Name (Legal Business Name): WILLIAM A. GRAY, D.M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9911 KENNERLY RD SUITE E
SAINT LOUIS MO
63128-2700
US

IV. Provider business mailing address

9911 KENNERLY RD SUITE E
SAINT LOUIS MO
63128-2700
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-4699
  • Fax: 314-842-3074
Mailing address:
  • Phone: 314-842-4699
  • Fax: 314-842-3074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DANA M POPPE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 314-842-4699