Provider Demographics
NPI:1710261383
Name:ANITA A GRAY DDS PA PSC
Entity Type:Organization
Organization Name:ANITA A GRAY DDS PA PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-745-4455
Mailing Address - Street 1:1303 W LEXINGTON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-3100
Mailing Address - Country:US
Mailing Address - Phone:859-745-4455
Mailing Address - Fax:859-745-4466
Practice Address - Street 1:1303 W LEXINGTON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-3100
Practice Address - Country:US
Practice Address - Phone:859-745-4455
Practice Address - Fax:859-745-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100179950Medicaid