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General NPI Number Information
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NPI Number | 1043594773
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Entity Type | Individual
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Provider Name | MATTHEW LYNN GRAY D.D.S
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Gender | Male
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Dates
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Enumeration Date | 09/29/2011
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Last Update Date | 09/16/2015
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Provider Practice Location Address
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Address Line | 3670 WOODWARD AVE SUITE 101B
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City | DETROIT
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State | MI
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Zip | 48201-2455
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Country | US
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Telephone | 313-355-1665
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Fax | 313-831-9064
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Provider Business Mailing Address
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Address Line | 2409 TUFTS AVE
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City | ROYAL OAK
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State | MI
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Zip | 48067-4039
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Country | US
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Telephone | 313-421-0079
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901020479
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License Number State | MI
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