Provider Demographics
NPI:1760680664
Name:GRAY, KENDRICK DORON (DDS)
Entity Type:Individual
Prefix:
First Name:KENDRICK
Middle Name:DORON
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S 173RD DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1951
Mailing Address - Country:US
Mailing Address - Phone:623-882-8348
Mailing Address - Fax:
Practice Address - Street 1:1701 E THOMAS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7646
Practice Address - Country:US
Practice Address - Phone:602-253-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ232643Medicaid