Provider Demographics
NPI:1578778270
Name:GRAVES, STACEY LEIGH
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LEIGH
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1788 FRIAR TUCK RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2614
Mailing Address - Country:US
Mailing Address - Phone:404-875-9675
Mailing Address - Fax:
Practice Address - Street 1:229 PEACHTREE ST NE
Practice Address - Street 2:SUITE 206
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1601
Practice Address - Country:US
Practice Address - Phone:404-522-7913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7359124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist