Provider Demographics
NPI:1942211628
Name:GRABER, GREGORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:GRABER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20100 N 78TH PL APT 1123
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-3835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10049 E DYNAMITE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3694
Practice Address - Country:US
Practice Address - Phone:480-513-6864
Practice Address - Fax:480-538-5258
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6487122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ107483Medicaid