Provider Demographics
NPI:1699988790
Name:GRAY, BRENT WAYNE (DMD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WAYNE
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 1:1445 N 400 E STE 2
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7564
Mailing Address - Country:US
Mailing Address - Phone:435-752-4136
Mailing Address - Fax:435-752-5177
Practice Address - Street 1:1445 N 400 E STE 2
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7564
Practice Address - Country:US
Practice Address - Phone:435-752-4136
Practice Address - Fax:435-752-5177
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT276161-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist