Provider Demographics
NPI:1790763258
Name:JOHN I. GRAY, III, PSC
Entity Type:Organization
Organization Name:JOHN I. GRAY, III, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:I
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-744-0677
Mailing Address - Street 1:1303 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-3100
Mailing Address - Country:US
Mailing Address - Phone:859-744-0677
Mailing Address - Fax:859-745-4466
Practice Address - Street 1:1303 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-3100
Practice Address - Country:US
Practice Address - Phone:859-744-0677
Practice Address - Fax:859-745-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61941274Medicaid
KY64042104Medicaid
KY65911885Medicaid
KY60042108Medicaid
KY60042108Medicaid
KY0605601Medicare ID - Type Unspecified
KY65911885Medicaid
KY0605604Medicare ID - Type Unspecified