Healthcare Provider Details

I. General information

NPI: 1578498804
Provider Name (Legal Business Name): REAGAN GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2953 BROAD AVE
MEMPHIS TN
38112-2957
US

IV. Provider business mailing address

610 BIG LAKE RD
MARION AR
72364-2657
US

V. Phone/Fax

Practice location:
  • Phone: 901-842-3171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13207
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: