Healthcare Provider Details

I. General information

NPI: 1942539994
Provider Name (Legal Business Name): JAMES ANTWAN GRAY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 SABRE ST SUITE 260
VIRGINIA BEACH VA
23452-7365
US

IV. Provider business mailing address

2875 SABRE ST SUITE 260
VIRGINIA BEACH VA
23452-7365
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-6886
  • Fax: 757-499-3464
Mailing address:
  • Phone: 757-499-6886
  • Fax: 757-499-3464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401414422
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: