Provider Demographics
NPI:1497728653
Name:BRAY, KENNETH ELLIS (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ELLIS
Last Name:BRAY
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 1:10151 MONTGOMERY BLVD NE
Mailing Address - Street 2:BLDG. 2 SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3670
Mailing Address - Country:US
Mailing Address - Phone:505-830-3636
Mailing Address - Fax:505-830-2305
Practice Address - Street 1:10151 MONTGOMERY BLVD NE
Practice Address - Street 2:BLDG. 2 SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3670
Practice Address - Country:US
Practice Address - Phone:505-830-3636
Practice Address - Fax:505-830-2305
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD11371223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics