Healthcare Provider Details

I. General information

NPI: 1104837962
Provider Name (Legal Business Name): DAVID ALAN GRAVES D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W POPLAR ST
ELIZABETHTOWN KY
42701-2410
US

IV. Provider business mailing address

501 W POPLAR ST
ELIZABETHTOWN KY
42701-2410
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-6156
  • Fax: 270-765-6157
Mailing address:
  • Phone: 270-765-6156
  • Fax: 270-765-6157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5285
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5285
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: