Provider Demographics
NPI:1073623047
Name:GRAY, EDWARD JOHN (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:GRAY
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 VIRGINIA RANCH RD STE 1A
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5764
Mailing Address - Country:US
Mailing Address - Phone:775-782-6491
Mailing Address - Fax:775-782-6492
Practice Address - Street 1:1516 VIRGINIA RANCH RD STE 1A
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5764
Practice Address - Country:US
Practice Address - Phone:775-782-6491
Practice Address - Fax:775-782-6492
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2-341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV900024470OtherTAX ID