=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982675831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL MAURICE WRAY DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NAVAL BRANCH HEALTH CLINIC JACKSONVILLE BOX 8 BLDG 964
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32212-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-542-3441
-----------------------------------------------------
Fax | 904-542-4937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | NAVAL BRANCH HEALTH CLINIC JACKSONVILLE BOX 8 BLDG 964
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32212-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-542-3441
-----------------------------------------------------
Fax | 904-542-4937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6197
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------