Provider Demographics
NPI:1073538781
Name:GRAHAM, ERIC ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ALBERT
Last Name:GRAHAM
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 1:336 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIGONIER
Mailing Address - State:PA
Mailing Address - Zip Code:15658-1418
Mailing Address - Country:US
Mailing Address - Phone:724-238-6624
Mailing Address - Fax:724-238-6624
Practice Address - Street 1:336 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LIGONIER
Practice Address - State:PA
Practice Address - Zip Code:15658-1418
Practice Address - Country:US
Practice Address - Phone:724-238-6624
Practice Address - Fax:724-238-6624
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-018558-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005325110001Medicaid