MEDICARE: DR. CHARLES D GRAY 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	1223G0001X	General Practice Dentistry	1001576	WI

General Provider Information

NPI Number	:	1356870463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES D GRAY DMD

Provider Business Mailing Address
First Line	:	1123 SUFFOLK DR
Second Line	:
City	:	JANESVILLE
State	:	WI
Zip	:	53546-1608
Country	:	US
Telephone Number	:	608-752-2665
Fax Number	:

Provider Business Practice Location Address
First Line	:	1123 SUFFOLK DR
Second Line	:
City	:	JANESVILLE
State	:	WI
Zip	:	53546-1608
Country	:	US
Telephone Number	:	608-752-2665
Fax Number	:

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

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	11/19/2025

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