MEDICARE: DR. PHILLIP MARTIN RAY JR. 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	122300000X	Dentist	11620	TN

General Provider Information

NPI Number	:	1437720190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILLIP MARTIN RAY JR. DMD

Provider Business Mailing Address
First Line	:	874 GLENRAVEN DR
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-8279
Country	:	US
Telephone Number	:	678-995-2281
Fax Number	:

Provider Business Practice Location Address
First Line	:	3603 INDIANA AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5803
Country	:	US
Telephone Number	:	270-798-3675
Fax Number	:

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

Provider Enumeration Date	:	07/05/2021
Last Update Date	:	03/24/2023

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