Provider Demographics
NPI:1205194404
Name:HARGRAVES, RACHEL THERESA (DDS)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:THERESA
Last Name:HARGRAVES
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 1:3681 E LYDIUS ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12303-3562
Mailing Address - Country:US
Mailing Address - Phone:518-928-5707
Mailing Address - Fax:
Practice Address - Street 1:30 ROUND LAKE RD
Practice Address - Street 2:
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019-1130
Practice Address - Country:US
Practice Address - Phone:518-899-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 20359122300000X
NY056649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist