Provider Demographics
NPI:1164974184
Name:GRAVES, MARK II (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GRAVES
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1523
Mailing Address - Country:US
Mailing Address - Phone:270-202-8168
Mailing Address - Fax:
Practice Address - Street 1:1175 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-3337
Practice Address - Country:US
Practice Address - Phone:270-383-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9858122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist