MEDICARE: GRAY COSMETIC & FAMILY DENTISTRY

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	122300000X	Dentist	21297	TX
2	2085R0202X	Diagnostic Radiology Physician	21297	TX

General Provider Information

NPI Number	:	1104079334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAY COSMETIC & FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	2701 W CUTHBERT AVE
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79701-3819
Country	:	US
Telephone Number	:	432-694-5741
Fax Number	:	432-694-5815

Provider Business Practice Location Address
First Line	:	2701 W CUTHBERT AVE
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79701-3819
Country	:	US
Telephone Number	:	432-694-5741
Fax Number	:	432-694-5815

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHET KENNETH GRAY
Credential	:	D.D.S.
Telephone Number	:	432-694-5741

Provider Enumeration Date	:	10/31/2008
Last Update Date	:	11/10/2008

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