Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | DS040890 | PA |
NPI | 1023665601 |
---|---|
Provider Name | Holly Gray |
First Address | Philadelphia, PA 19146-1852 |
Second Address | Philadelphia, PA 19146-1852 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2019 |
Last Update Date | 20/08/2019 |