Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 5360 | AL |
NPI | 1073607404 |
---|---|
Provider Name | Dr. Jordan Holt Gray |
First Address | Bessemer, AL 35022-5478 |
Second Address | Bessemer, AL 35022-5478 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/10/2006 |
Last Update Date | 11/05/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5360 | LICENSE NUMBER (01) | AL |