Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | IL |
NPI | 1043399132 |
---|---|
Provider Name | Dr. Gerald D Gray |
First Address | Crystal Lake, IL 60014-1401 |
Second Address | Crystal Lake, IL 60014-1401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2006 |
Last Update Date | 08/07/2007 |