Provider Demographics
NPI:1245664143
Name:GRAY, TINA L (DDS)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 TAMARACK DRIVE
Mailing Address - Street 2:DENTAC - ALASKA
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3406 ALDER AVE
Practice Address - Street 2:DENTAC - ALASKA
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:907-353-2917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011981A122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist