Provider Demographics
NPI:1619085362
Name:GRAY, BRETT C (DMD MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:C
Last Name:GRAY
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 KLONDIKE ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094
Mailing Address - Country:US
Mailing Address - Phone:770-483-9692
Mailing Address - Fax:678-487-1004
Practice Address - Street 1:1463 KLONDIKE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:770-483-9692
Practice Address - Fax:678-487-1004
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0477551223S0112X
KY72351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H15748Medicare UPIN
GA1708Medicare ID - Type UnspecifiedGP