Provider Demographics
NPI:1528105004
Name:GRAY, PETER D (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:D
Last Name:GRAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 COUNTY ROUTE 57
Mailing Address - Street 2:P. O. BOX 206
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-3301
Mailing Address - Country:US
Mailing Address - Phone:315-695-6500
Mailing Address - Fax:
Practice Address - Street 1:251 COUNTY ROUTE 57
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:NY
Practice Address - Zip Code:13135-3301
Practice Address - Country:US
Practice Address - Phone:315-695-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031557122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist