Provider Demographics
NPI:1497104871
Name:GRAY, HARDY LAMAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:HARDY
Middle Name:LAMAR
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 1:3362 GREYSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-1096
Mailing Address - Country:US
Mailing Address - Phone:229-242-0063
Mailing Address - Fax:
Practice Address - Street 1:3362 GREYSTONE WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1096
Practice Address - Country:US
Practice Address - Phone:229-242-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist