MEDICARE: DR. STUART LEE GRAVES DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	347288	OTHER		UNITED CONCORDIA
2	64390001	OTHER	DC	CAREFIRST BCBS
3	209216	OTHER	VA	ANTHEM BCBS

General Provider Information

NPI Number	:	1003952003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STUART LEE GRAVES DDS

Provider Business Mailing Address
First Line	:	5206 LYNGATE CT
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-1631
Country	:	US
Telephone Number	:	703-425-5010
Fax Number	:	703-323-7287

Provider Business Practice Location Address
First Line	:	5206 LYNGATE CT
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-1631
Country	:	US
Telephone Number	:	703-425-5010
Fax Number	:	703-323-7287

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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