1871506881 NPI number — JAMES DOUGLAS GRAY DDS DENTIST

Table of content: JAMES DOUGLAS GRAY DDS DENTIST (NPI 1871506881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871506881 NPI number — JAMES DOUGLAS GRAY DDS DENTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
JAMES
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS DENTIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAY
Provider Other First Name:
J
Provider Other Middle Name:
DOUGLAS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1871506881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 872
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OROFINO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83544-0872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-476-4917
Provider Business Mailing Address Fax Number:
208-476-4071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OROFINO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83544-0872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-4917
Provider Business Practice Location Address Fax Number:
208-476-4071
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D1776 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40523 . This is a "REJENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 67835 . This is a "B CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 001238000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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