Provider Demographics
NPI:1073704904
Name:GRAY, MATTHEW PHILIP (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PHILIP
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 1:11920 E 86TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055
Mailing Address - Country:US
Mailing Address - Phone:918-272-9519
Mailing Address - Fax:918-272-9510
Practice Address - Street 1:11920 E 86TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055
Practice Address - Country:US
Practice Address - Phone:918-272-9519
Practice Address - Fax:918-272-9510
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist