Provider Demographics
NPI:1366796245
Name:DR. DUSTIN RAY, PLLC
Entity type:Organization
Organization Name:DR. DUSTIN RAY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-224-2292
Mailing Address - Street 1:777 MAIN ST
Mailing Address - Street 2:640
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-5304
Mailing Address - Country:US
Mailing Address - Phone:817-224-2292
Mailing Address - Fax:866-279-9993
Practice Address - Street 1:777 MAIN ST
Practice Address - Street 2:640
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5304
Practice Address - Country:US
Practice Address - Phone:817-224-2292
Practice Address - Fax:866-279-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty