Provider Demographics
NPI:1689384836
Name:GRAY, MICHAEL YLDEMAR SR
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:YLDEMAR
Last Name:GRAY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580A QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-8049
Mailing Address - Country:US
Mailing Address - Phone:917-756-9584
Mailing Address - Fax:
Practice Address - Street 1:851 SEAN DR STE 2
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-9009
Practice Address - Country:US
Practice Address - Phone:419-552-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.027036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program