Provider Demographics
NPI:1326016908
Name:GRAY, JILL LAVONNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:LAVONNE
Last Name:GRAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66508-1907
Mailing Address - Country:US
Mailing Address - Phone:785-562-5323
Mailing Address - Fax:844-270-3105
Practice Address - Street 1:107 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66508-1831
Practice Address - Country:US
Practice Address - Phone:785-562-5323
Practice Address - Fax:785-562-3428
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS 602121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS00001747982OtherTRICARE
KS0000421758OtherBCBS
KS200328140AMedicaid