Provider Demographics
NPI:1326268640
Name:L DOUGLAS GRAY DDS AND KENNETH K LO DDS PS
Entity Type:Organization
Organization Name:L DOUGLAS GRAY DDS AND KENNETH K LO DDS PS
Other - Org Name:ROOSEVELT DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-524-6100
Mailing Address - Street 1:6417 ROOSEVELT WAY NE
Mailing Address - Street 2:#206
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115
Mailing Address - Country:US
Mailing Address - Phone:206-524-6100
Mailing Address - Fax:206-522-4608
Practice Address - Street 1:6417 ROOSEVELT WAY NE
Practice Address - Street 2:#206
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115
Practice Address - Country:US
Practice Address - Phone:206-524-6100
Practice Address - Fax:206-522-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA114742OtherL AND I