Provider Demographics
NPI:1093817710
Name:GRAVES, DE SHAUNDA TAMITA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DE SHAUNDA
Middle Name:TAMITA
Last Name:GRAVES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9413 GLENFIELD CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-3817
Mailing Address - Country:US
Mailing Address - Phone:713-283-5210
Mailing Address - Fax:713-283-5488
Practice Address - Street 1:9413 GLENFIELD CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-3817
Practice Address - Country:US
Practice Address - Phone:713-283-5210
Practice Address - Fax:713-283-5488
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX194831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0095630-001Medicaid