Provider Demographics
NPI:1336365956
Name:WILLIAM A. GRAY, D.M.D., LLC
Entity Type:Organization
Organization Name:WILLIAM A. GRAY, D.M.D., LLC
Other - Org Name:ST. LOUIS SOUTH ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:POPPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-842-4699
Mailing Address - Street 1:9911 KENNERLY RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2700
Mailing Address - Country:US
Mailing Address - Phone:314-842-4699
Mailing Address - Fax:314-842-3074
Practice Address - Street 1:9911 KENNERLY RD
Practice Address - Street 2:SUITE E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2700
Practice Address - Country:US
Practice Address - Phone:314-842-4699
Practice Address - Fax:314-842-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV18886Medicare UPIN