Provider Demographics
NPI:1699181248
Name:WALKER, MICHELLE GRAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:GRAY
Last Name:WALKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:ASHLEY
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1700 W C PL
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801
Mailing Address - Country:US
Mailing Address - Phone:479-968-1470
Mailing Address - Fax:
Practice Address - Street 1:1700 W C PL
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8413122300000X, 1223G0001X
NMDD47341223G0001X
TX361341223G0001X
AR46811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist