Provider Demographics
NPI:1003148263
Name:GRAY, SHALIENA K (RDH)
Entity Type:Individual
Prefix:
First Name:SHALIENA
Middle Name:K
Last Name:GRAY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 EL CERRO LOOP
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9505
Mailing Address - Country:US
Mailing Address - Phone:505-410-5305
Mailing Address - Fax:
Practice Address - Street 1:2050 A SECOND ST SE
Practice Address - Street 2:KIRTLAND AIRFORCE BASE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87117-0001
Practice Address - Country:US
Practice Address - Phone:505-846-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH 2816124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist