Provider Demographics
NPI:1366557019
Name:MADRAY, GREGORY ALAN (DDS PC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALAN
Last Name:MADRAY
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WEST CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545
Mailing Address - Country:US
Mailing Address - Phone:912-427-6404
Mailing Address - Fax:912-427-8628
Practice Address - Street 1:107 WEST CHERRY ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545
Practice Address - Country:US
Practice Address - Phone:912-427-6404
Practice Address - Fax:912-427-8628
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10343 GA122300000X
GA10343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00325619DMedicaid