MEDICARE: FULL SMILE DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1548872542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL SMILE DENTAL, PLLC

Provider Business Mailing Address
First Line	:	5051 S SONCY RD
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119-6667
Country	:	US
Telephone Number	:	63-531-0558
Fax Number	:	806-353-7077

Provider Business Practice Location Address
First Line	:	4515 VAN WINKLE DR
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119-6423
Country	:	US
Telephone Number	:	806-358-0368
Fax Number	:	806-353-7077

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM EDWARD GRAVES
Credential	:	DMD
Telephone Number	:	806-353-1055

Provider Enumeration Date	:	08/20/2020
Last Update Date	:	11/27/2023

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