Provider Demographics
NPI:1598420937
Name:GRAY, SORRELL JOLENE
Entity Type:Individual
Prefix:
First Name:SORRELL
Middle Name:JOLENE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SORRELL
Other - Middle Name:JOLENE
Other - Last Name:SABIDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7105 SW HAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-997-2884
Mailing Address - Fax:
Practice Address - Street 1:7105 SW HAMPTON STRRET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-624-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR115631126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant