Provider Demographics
NPI:1205829041
Name:GRAY, CHARLES M (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1505 EMERALD PLAZA
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-1501
Mailing Address - Country:US
Mailing Address - Phone:979-764-7101
Mailing Address - Fax:979-764-7115
Practice Address - Street 1:1505 EMERALD PLAZA
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-1501
Practice Address - Country:US
Practice Address - Phone:979-764-7101
Practice Address - Fax:979-764-7115
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110873003Medicaid
TX813315OtherUNITED CONCORDIA
TX84V341OtherBLUE CROSS BLUE SHIELD
TX84V341OtherBLUE CROSS BLUE SHIELD
TX813315OtherUNITED CONCORDIA