Provider Demographics
NPI:1114407871
Name:GRAVES, CARRIE (RDH, PRDH)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:RDH, PRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:NE
Mailing Address - Zip Code:68434-1081
Mailing Address - Country:US
Mailing Address - Phone:402-432-7421
Mailing Address - Fax:
Practice Address - Street 1:858 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-1081
Practice Address - Country:US
Practice Address - Phone:402-432-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1119124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist