Provider Demographics
NPI:1902343148
Name:MINDA J GRAY
Entity Type:Organization
Organization Name:MINDA J GRAY
Other - Org Name:OMOS PARK COSMETIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:210-824-2303
Mailing Address - Street 1:351 E HILDEBRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2412
Mailing Address - Country:US
Mailing Address - Phone:210-824-2303
Mailing Address - Fax:
Practice Address - Street 1:351 E HILDEBRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2412
Practice Address - Country:US
Practice Address - Phone:210-824-2303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty