Provider Demographics
NPI:1811007677
Name:GRAY, EDWARD WYATT (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WYATT
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 1:1776 GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109
Mailing Address - Country:US
Mailing Address - Phone:858-270-7540
Mailing Address - Fax:858-270-3428
Practice Address - Street 1:1776 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109
Practice Address - Country:US
Practice Address - Phone:858-270-7540
Practice Address - Fax:858-270-3428
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31272122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADD031272OtherDEPT OF CONSUMER AFFAIRS
CADD031272OtherDEPT OF CONSUMER AFFAIRS