Healthcare Provider Details

I. General information

NPI: 1235142506
Provider Name (Legal Business Name): ANDREW EDWARD GRAVES D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 HELEN KELLER BLVD STE 300
TUSCALOOSA AL
35404-2962
US

IV. Provider business mailing address

621 HELEN KELLER BLVD STE 300
TUSCALOOSA AL
35404-2962
US

V. Phone/Fax

Practice location:
  • Phone: 205-633-6363
  • Fax: 205-633-6372
Mailing address:
  • Phone: 205-633-6363
  • Fax: 205-633-6372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberAL4638
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: