Provider Demographics
NPI:1184772774
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:PRESIDENT
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:859-498-6204
Mailing Address - Street 1:25 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1267
Mailing Address - Country:US
Mailing Address - Phone:859-498-6204
Mailing Address - Fax:859-498-6205
Practice Address - Street 1:25 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1267
Practice Address - Country:US
Practice Address - Phone:859-498-6204
Practice Address - Fax:859-498-6205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2022-10-28
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
KY60038353Medicaid
KY61941258Medicaid
KY64180185Medicaid
KY60002284Medicaid
KY64942584Medicaid
KY65911877Medicaid