Provider Demographics
NPI:1346973849
Name:RAY, NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:RAY
Suffix:
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 1:3833 S BOND AVE APT 339
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4739
Mailing Address - Country:US
Mailing Address - Phone:801-842-9166
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-326-1297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-03
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018002217204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery