Provider Demographics
NPI:1073664314
Name:ENNEKING, RAY G (DDS)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:G
Last Name:ENNEKING
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 1:316 S AUBURN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7298
Mailing Address - Country:US
Mailing Address - Phone:530-274-0920
Mailing Address - Fax:530-274-8935
Practice Address - Street 1:316 S AUBURN ST STE 5
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7298
Practice Address - Country:US
Practice Address - Phone:530-274-0920
Practice Address - Fax:530-274-8935
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA185451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice