Healthcare Provider Details

I. General information

NPI: 1508048521
Provider Name (Legal Business Name): JONATHAN RUSSELL GRAY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 20TH AVE S
FARGO ND
58103-7436
US

IV. Provider business mailing address

4344 20TH AVE S
FARGO ND
58103-7436
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-5969
  • Fax:
Mailing address:
  • Phone: 701-239-5969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2096
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: