=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336238369
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT WARREN GRAVES DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ONE MEDICAL CENTER DR.
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-293-2841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 SCHUBERT PL
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-599-1049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | WV1829
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------