MEDICARE: JOHN I GRAY III DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	306	KY
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	4210	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043396963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN I GRAY III DMD

Provider Business Mailing Address
First Line	:	25 E HIGH ST
Second Line	:
City	:	MT STERLING
State	:	KY
Zip	:	40353-1267
Country	:	US
Telephone Number	:	859-498-6204
Fax Number	:	859-498-6205

Provider Business Practice Location Address
First Line	:	25 E HIGH ST
Second Line	:
City	:	MT STERLING
State	:	KY
Zip	:	40353-1267
Country	:	US
Telephone Number	:	859-498-6204
Fax Number	:	859-498-6205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	09/12/2019

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Directions to “ JOHN I GRAY III DMD” Practice Location

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