Provider Demographics
NPI:1629215983
Name:ANGELA GRAY FAMILY DENTISTRY INC.
Entity Type:Organization
Organization Name:ANGELA GRAY FAMILY DENTISTRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-382-4729
Mailing Address - Street 1:2650 JOHN HARDEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-1819
Mailing Address - Country:US
Mailing Address - Phone:501-982-4729
Mailing Address - Fax:
Practice Address - Street 1:2650 JOHN HARDEN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-1819
Practice Address - Country:US
Practice Address - Phone:501-982-4729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR172956631Medicaid