Provider Demographics
NPI:1164503710
Name:BRAY, GORDON WARREN JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:WARREN
Last Name:BRAY
Suffix:JR
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 1:1376 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2435
Mailing Address - Country:US
Mailing Address - Phone:864-250-1100
Mailing Address - Fax:864-250-1604
Practice Address - Street 1:1376 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2435
Practice Address - Country:US
Practice Address - Phone:864-250-1100
Practice Address - Fax:864-250-1604
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2521223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC433103Medicaid