Provider Demographics
NPI:1548357577
Name:GRAY, RONALD WENDELL (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WENDELL
Last Name:GRAY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 CHESTERFIELD AVE
Mailing Address - Street 2:PO BOX 906
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-3508
Mailing Address - Country:US
Mailing Address - Phone:803-283-9969
Mailing Address - Fax:803-283-9907
Practice Address - Street 1:406 CHESTERFIELD AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-3508
Practice Address - Country:US
Practice Address - Phone:803-283-9969
Practice Address - Fax:803-283-9907
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 21051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC436128Medicaid