Provider Demographics
NPI:1497329304
Name:GRAY, SELENA (DDS)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 29TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2914
Mailing Address - Country:US
Mailing Address - Phone:812-890-8475
Mailing Address - Fax:
Practice Address - Street 1:2528 29TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-2914
Practice Address - Country:US
Practice Address - Phone:310-853-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101191-8751223G0001X
CA1086141223G0001X
MO20230398721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice