Provider Demographics
NPI:1518276559
Name:GRAY, JERRY WAYNE (RDH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:GRAY
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 S RURAL RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3747
Mailing Address - Country:US
Mailing Address - Phone:480-456-0821
Mailing Address - Fax:
Practice Address - Street 1:6601 S RURAL RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3747
Practice Address - Country:US
Practice Address - Phone:480-456-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4544124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist