Provider Demographics
NPI:1316051352
Name:GRAVES, JOHN JUDSON (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JUDSON
Last Name:GRAVES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E AUSTIN ST
Mailing Address - Street 2:P.O.BOX 791
Mailing Address - City:KERMIT
Mailing Address - State:TX
Mailing Address - Zip Code:79745-3222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 E AUSTIN ST
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:TX
Practice Address - Zip Code:79745-3222
Practice Address - Country:US
Practice Address - Phone:432-586-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice