Provider Demographics
NPI:1679596357
Name:GRAY, MATTHEW ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:GRAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1506 ANNAPOLIS WAY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-2997
Mailing Address - Country:US
Mailing Address - Phone:678-344-2026
Mailing Address - Fax:770-934-1240
Practice Address - Street 1:2300 HENDERSON MILL RD NE
Practice Address - Street 2:STE 401
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2745
Practice Address - Country:US
Practice Address - Phone:770-938-3277
Practice Address - Fax:770-934-1240
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice