MEDICARE: KENNETH K GRAY DDS

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	2901013747	MI

General Provider Information

NPI Number	:	1467534123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH K GRAY DDS

Provider Business Mailing Address
First Line	:	4550 DIVISION AVE S
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49548-4373
Country	:	US
Telephone Number	:	616-534-8754
Fax Number	:

Provider Business Practice Location Address
First Line	:	4550 DIVISION AVE S
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49548-4373
Country	:	US
Telephone Number	:	616-534-8754
Fax Number	:

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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