Healthcare Provider Details

I. General information

NPI: 1972341642
Provider Name (Legal Business Name): LYDIA MARIE GRAVES DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100 BOX LANDSTUHL
APO AE
09180-3100
US

IV. Provider business mailing address

LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100 APOAE 09180-3100
APO AE
09180-3100
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-7028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11136
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: