Provider Demographics
NPI:1013210673
Name:JAMES G. GRAVES, D.M.D., P.L.L.C.
Entity Type:Organization
Organization Name:JAMES G. GRAVES, D.M.D., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-562-9484
Mailing Address - Street 1:522 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2657
Mailing Address - Country:US
Mailing Address - Phone:662-562-9484
Mailing Address - Fax:662-301-8222
Practice Address - Street 1:522 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2657
Practice Address - Country:US
Practice Address - Phone:662-562-9484
Practice Address - Fax:662-301-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2275-861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060223Medicaid