Provider Demographics
NPI:1720482607
Name:JEANNE GRAVES
Entity Type:Organization
Organization Name:JEANNE GRAVES
Other - Org Name:DENTAL HYGIENE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:719-542-2489
Mailing Address - Street 1:2099 W. US HWY 50
Mailing Address - Street 2:SUITE #180
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1673
Mailing Address - Country:US
Mailing Address - Phone:719-542-2489
Mailing Address - Fax:
Practice Address - Street 1:2099 W. US HWY 50
Practice Address - Street 2:SUITE #180
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1673
Practice Address - Country:US
Practice Address - Phone:719-542-2489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04014437Medicaid