MEDICARE: SELENA 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	1223G0001X	General Practice Dentistry	101191-875	WI
2	1223G0001X	General Practice Dentistry	7548	LA
3	1223G0001X	General Practice Dentistry	2023039872	MO
4	1223G0001X	General Practice Dentistry	108614	CA

General Provider Information

NPI Number	:	1497329304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELENA GRAY DDS

Provider Business Mailing Address
First Line	:	4925 S ROCHEBLAVE ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70125-4413
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 SAINT CHARLES AVE
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70130-4436
Country	:	US
Telephone Number	:	504-304-9929
Fax Number	:

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

Provider Enumeration Date	:	05/14/2021
Last Update Date	:	06/09/2026

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