Provider Demographics
NPI:1205997608
Name:GRAY, SANDRA D (DMD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:GRAY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:PHIILP-ROUSSEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:61 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-2213
Practice Address - Country:US
Practice Address - Phone:973-675-1900
Practice Address - Fax:973-675-4021
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D101572500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1194996645Other444 WILLIAM STREET
NJ1836706Medicaid
NJ1836706Medicaid