Provider Demographics
NPI:1174624209
Name:GRAY, JEFFREY CLYDE (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CLYDE
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16520 DARTOLO RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-4666
Mailing Address - Country:US
Mailing Address - Phone:767-788-0750
Mailing Address - Fax:
Practice Address - Street 1:8555 FLETCHER PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3060
Practice Address - Country:US
Practice Address - Phone:619-337-7700
Practice Address - Fax:619-337-7710
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA346131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34613OtherLICENSE