Provider Demographics
NPI:1972341642
Name:GRAVES, LYDIA MARIE (DMD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 APACHE WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-8179
Mailing Address - Country:US
Mailing Address - Phone:859-801-3448
Mailing Address - Fax:
Practice Address - Street 1:6145 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5558
Practice Address - Country:US
Practice Address - Phone:270-412-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice