Provider Demographics
NPI:1386963718
Name:MOUTRAY, MELISSA MAE (MD DDS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MAE
Last Name:MOUTRAY
Suffix:
Gender:F
Credentials:MD DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 CAMPUS DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846
Mailing Address - Country:US
Mailing Address - Phone:602-272-0100
Mailing Address - Fax:620-271-0160
Practice Address - Street 1:311 CAMPUS DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846
Practice Address - Country:US
Practice Address - Phone:602-272-0100
Practice Address - Fax:620-271-0160
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SDD1107204E00000X
KS04-41292204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery