Provider Demographics
NPI:1437597598
Name:GRAVES, CARMEN VILLASANTE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:VILLASANTE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:NORA
Other - Last Name:VILLASANTE MERCADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:850 S WABASH AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3643
Mailing Address - Country:US
Mailing Address - Phone:312-356-4700
Mailing Address - Fax:
Practice Address - Street 1:850 S WABASH AVE STE 240
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3643
Practice Address - Country:US
Practice Address - Phone:312-356-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0310101223P0300X
TX320521223P0300X
ZZ221541223P0300X
IL021.0027921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics