Provider Demographics
NPI:1134235609
Name:BRAY, DMD & YOUNG, DMD, PC
Entity type:Organization
Organization Name:BRAY, DMD & YOUNG, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-489-1386
Mailing Address - Street 1:715 NORTHSIDE DR E
Mailing Address - Street 2:SUITE 5, PMB 395
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4712
Mailing Address - Country:US
Mailing Address - Phone:912-489-1386
Mailing Address - Fax:912-764-8533
Practice Address - Street 1:2 LESTER CT
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2118
Practice Address - Country:US
Practice Address - Phone:912-489-1386
Practice Address - Fax:912-764-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100991223P0221X
GA97931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00328622BMedicaid
GA00328314BMedicaid