Provider Demographics
NPI:1386212355
Name:GRAY, CODY (DMD)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:
Last Name:GRAY
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 1:4330 JOHNS CREEK PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6121
Mailing Address - Country:US
Mailing Address - Phone:770-622-1515
Mailing Address - Fax:
Practice Address - Street 1:4330 JOHNS CREEK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6121
Practice Address - Country:US
Practice Address - Phone:770-622-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1222791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice