MEDICARE: GRAY'S PERIODONTAL CENTER

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1952054793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAY'S PERIODONTAL CENTER

Provider Business Mailing Address
First Line	:	1244 PERIMETER PKWY STE 442
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5699
Country	:	US
Telephone Number	:	757-716-3539
Fax Number	:	757-716-3546

Provider Business Practice Location Address
First Line	:	1244 PERIMETER PKWY STE 442
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5699
Country	:	US
Telephone Number	:	757-716-3539
Fax Number	:	757-716-3546

Authorized Official
Title or Position	:	CEO
Name	:	DR. ANDREW GRAY
Credential	:	DDS
Telephone Number	:	757-716-3539

Provider Enumeration Date	:	02/01/2022
Last Update Date	:	02/01/2022

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Directions to “GRAY'S PERIODONTAL CENTER ” Practice Location

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