Provider Demographics
NPI:1043396963
Name:GRAY, JOHN I III (DMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:I
Last Name:GRAY
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1267
Mailing Address - Country:US
Mailing Address - Phone:859-498-6204
Mailing Address - Fax:859-498-6205
Practice Address - Street 1:25 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1267
Practice Address - Country:US
Practice Address - Phone:859-498-6204
Practice Address - Fax:859-498-6205
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY306204E00000X
KY42101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64942584Medicaid
KY0605801Medicare ID - Type Unspecified
KY64942584Medicaid