Provider Demographics
NPI:1104079334
Name:GRAY COSMETIC & FAMILY DENTISTRY
Entity type:Organization
Organization Name:GRAY COSMETIC & FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHET
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:432-694-5741
Mailing Address - Street 1:2701 W CUTHBERT AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-3819
Mailing Address - Country:US
Mailing Address - Phone:432-694-5741
Mailing Address - Fax:432-694-5815
Practice Address - Street 1:2701 W CUTHBERT AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-3819
Practice Address - Country:US
Practice Address - Phone:432-694-5741
Practice Address - Fax:432-694-5815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21297122300000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty