Provider Demographics
NPI:1083359368
Name:FULL SMILE PERIODONTICS, PLLC
Entity Type:Organization
Organization Name:FULL SMILE PERIODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:806-353-1055
Mailing Address - Street 1:5051 S SONCY RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6667
Mailing Address - Country:US
Mailing Address - Phone:806-353-1055
Mailing Address - Fax:806-353-7077
Practice Address - Street 1:4515 VAN WINKLE DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-6423
Practice Address - Country:US
Practice Address - Phone:806-699-6111
Practice Address - Fax:806-353-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty