Provider Demographics
NPI:1275628539
Name:GRAY, RICHARD MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
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:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:MA
Mailing Address - Zip Code:02338
Mailing Address - Country:US
Mailing Address - Phone:781-293-5633
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT 160 ST
Practice Address - Street 2:BROCKTON VA MEDICAL CTR
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02401
Practice Address - Country:US
Practice Address - Phone:774-826-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice