Provider Demographics
NPI:1043594773
Name:GRAY, MATTHEW LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 TUFTS AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4039
Mailing Address - Country:US
Mailing Address - Phone:313-421-0079
Mailing Address - Fax:
Practice Address - Street 1:3670 WOODWARD AVE
Practice Address - Street 2:SUITE 101B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2455
Practice Address - Country:US
Practice Address - Phone:313-355-1665
Practice Address - Fax:313-831-9064
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010204791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice