Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 4210 | KY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 306 | KY |
NPI | 1043396963 |
---|---|
Provider Name | John I Gray III |
First Address | Mt Sterling, KY 40353-1267 |
Second Address | Mt Sterling, KY 40353-1267 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2006 |
Last Update Date | 12/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64942584 | (05) | KY |
T54062 | (02) | KY |