Provider Demographics
NPI:1750678538
Name:GRAY, JESSE LANE (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:LANE
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 HENRY CHAPPLE ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106
Mailing Address - Country:US
Mailing Address - Phone:406-259-7438
Mailing Address - Fax:
Practice Address - Street 1:625 HERRY CHAPPLE ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59106
Practice Address - Country:US
Practice Address - Phone:406-259-7438
Practice Address - Fax:406-259-9729
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE69391223S0112X
WY14741223S0112X
MT135051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery