Provider Demographics
NPI:1780819599
Name:GRAY, MEGAN (DDS)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 57TH ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4146
Mailing Address - Country:US
Mailing Address - Phone:262-764-3622
Mailing Address - Fax:262-764-3636
Practice Address - Street 1:6226 14TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4413
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-764-3636
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027924122300000X
FLFD1476488122300000X
WI1001011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780819599Medicaid