Provider Demographics
NPI:1659457885
Name:GRAY, TYSON N (DMD)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:N
Last Name:GRAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1510
Mailing Address - Country:US
Mailing Address - Phone:208-888-2026
Mailing Address - Fax:208-888-2094
Practice Address - Street 1:813 STILSON RD. SUITE B
Practice Address - Street 2:MILLENNIUM FAMILY DENTAL BOISE LLC
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703
Practice Address - Country:US
Practice Address - Phone:208-342-4644
Practice Address - Fax:208-888-2094
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-37991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806871400Medicaid