Provider Demographics
NPI:1740559210
Name:GRAVES, BROOKS J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BROOKS
Middle Name:J
Last Name:GRAVES
Suffix:
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 1:992 E US HIGHWAY 80 STE D
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-8704
Mailing Address - Country:US
Mailing Address - Phone:972-552-1012
Mailing Address - Fax:
Practice Address - Street 1:992 E US HIGHWAY 80 STE D
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8704
Practice Address - Country:US
Practice Address - Phone:972-552-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC71031223G0001X
TX27928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice