Provider Demographics
NPI:1922489673
Name:GRAY TEAM LLC
Entity Type:Organization
Organization Name:GRAY TEAM LLC
Other - Org Name:PARKWAY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-342-4644
Mailing Address - Street 1:813 N STILSON RD
Mailing Address - Street 2:STE:B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5119
Mailing Address - Country:US
Mailing Address - Phone:208-342-4644
Mailing Address - Fax:208-367-0283
Practice Address - Street 1:813 N STILSON RD
Practice Address - Street 2:STE:B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5119
Practice Address - Country:US
Practice Address - Phone:208-342-4644
Practice Address - Fax:208-367-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty