Provider Demographics
NPI:1790353084
Name:MCCRAY, JUSTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:MCCRAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 PROSPECT AVE E APT 707
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-2347
Mailing Address - Country:US
Mailing Address - Phone:601-383-1496
Mailing Address - Fax:
Practice Address - Street 1:1401 PROSPECT AVE E APT 707
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2347
Practice Address - Country:US
Practice Address - Phone:601-383-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS802245870Medicaid