Provider Demographics
NPI:1578001616
Name:JESSE R GRAY DDS PA
Entity Type:Organization
Organization Name:JESSE R GRAY DDS PA
Other - Org Name:NORTHWEST ORTHODONTICS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESS
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-521-4181
Mailing Address - Street 1:3119 E MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6617
Mailing Address - Country:US
Mailing Address - Phone:479-521-4181
Mailing Address - Fax:479-521-0442
Practice Address - Street 1:3119 E MISSION BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6617
Practice Address - Country:US
Practice Address - Phone:479-521-4181
Practice Address - Fax:479-521-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR34271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty