Provider Demographics
NPI:1376716662
Name:GRAY, NOWELL EVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NOWELL
Middle Name:EVAN
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NOWELL
Other - Middle Name:EVAN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:125 CHENOWETH LN
Mailing Address - Street 2:STE. 204
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2641
Mailing Address - Country:US
Mailing Address - Phone:502-897-5454
Mailing Address - Fax:502-897-6264
Practice Address - Street 1:125 CHENOWETH LN
Practice Address - Street 2:STE. 204
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2641
Practice Address - Country:US
Practice Address - Phone:502-897-5454
Practice Address - Fax:502-897-6264
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9705122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist