Provider Demographics
NPI:1356327639
Name:GRAVER, JAY DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:DOUGLAS
Last Name:GRAVER
Suffix:
Gender:M
Credentials:DMD
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Mailing Address - Street 1:1100 WILFORD HALL LOOP, BLDG 4554, ATTN: 59 MDW/SGHC
Mailing Address - Street 2:POC: MS DARLON JACKSON
Mailing Address - City:JBSA-LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-292-6552
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP, BLDG 4554, ATTN: 59 MDW/SGHC
Practice Address - Street 2:POC: MS DARLON JACKSON
Practice Address - City:JBSA-LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78256-9908
Practice Address - Country:US
Practice Address - Phone:210-292-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2019-08-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PADS025182L1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD 000Medicare UPIN