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General NPI Number Information
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NPI Number | 1578001616
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Entity Type | Organization
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Legal Business Name | JESSE R GRAY DDS PA
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Dates
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Enumeration Date | 02/09/2017
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Last Update Date | 02/09/2017
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Provider Practice Location Address
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Address Line | 3119 E MISSION BLVD
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-6617
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Country | US
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Telephone | 479-521-4181
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Fax | 479-521-0442
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Provider Business Mailing Address
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Address Line | 3119 E MISSION BLVD
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-6617
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Country | US
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Telephone | 479-521-4181
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Fax | 479-521-0442
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Authorized Official
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Title or Position | OWNER
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Name | DR. JESS R GRAY
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Credential | DDS
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Telephone | 479-521-4181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3427
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License Number State | AR
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