Healthcare Provider Details

I. General information

NPI: 1013356658
Provider Name (Legal Business Name): DANIEL RAYMOND GRAY DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2436 HIAWATHA DR NE
ALBUQUERQUE NM
87112-1922
US

IV. Provider business mailing address

2436 HIAWATHA DR NE
ALBUQUERQUE NM
87112-1922
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-5761
  • Fax:
Mailing address:
  • Phone: 505-550-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: