Provider Demographics
NPI:1871506881
Name:GRAY, JAMES DOUGLAS (DDS DENTIST)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DOUGLAS
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS DENTIST
Other - Prefix:
Other - First Name:J
Other - Middle Name:DOUGLAS
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 872
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-0872
Mailing Address - Country:US
Mailing Address - Phone:208-476-4917
Mailing Address - Fax:208-476-4071
Practice Address - Street 1:636 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-0872
Practice Address - Country:US
Practice Address - Phone:208-476-4917
Practice Address - Fax:208-476-4071
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID40523OtherREJENCE
ID67835OtherB CROSS
ID001238000Medicaid