Healthcare Provider Details

I. General information

NPI: 1497728653
Provider Name (Legal Business Name): KENNETH ELLIS BRAY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 MONTGOMERY BLVD NE BLDG. 2 SUITE B
ALBUQUERQUE NM
87111-3670
US

IV. Provider business mailing address

10151 MONTGOMERY BLVD NE BLDG. 2 SUITE B
ALBUQUERQUE NM
87111-3670
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-3636
  • Fax: 505-830-2305
Mailing address:
  • Phone: 505-830-3636
  • Fax: 505-830-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD1137
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: