Healthcare Provider Details

I. General information

NPI: 1760482046
Provider Name (Legal Business Name): DR. SHELDON MAURICE GRAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

4137 KIRBY PKWY SUITE 4
MEMPHIS TN
38115-6532
US

IV. Provider business mailing address

4137 KIRBY PKWY SUITE 4
MEMPHIS TN
38115
US

V. Phone/Fax

Practice location:
  • Phone: 901-433-0701
  • Fax: 901-433-0703
Mailing address:
  • Phone: 901-433-0701
  • Fax: 901-433-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS0000004417
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: