Provider Demographics
NPI:1194174904
Name:GRAY, MARK GREGORY II (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:GRAY
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1737
Mailing Address - Country:US
Mailing Address - Phone:304-657-8324
Mailing Address - Fax:
Practice Address - Street 1:200 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1737
Practice Address - Country:US
Practice Address - Phone:304-657-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist