Provider Demographics
NPI:1073785986
Name:GREGORY M. GRAHAM, DMD,LLC
Entity Type:Organization
Organization Name:GREGORY M. GRAHAM, DMD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:478-452-0270
Mailing Address - Street 1:385 MEADOW RIDGE DR
Mailing Address - Street 2:GREGORY M GRAHAM, DMD, LLC
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-8741
Mailing Address - Country:US
Mailing Address - Phone:478-452-0270
Mailing Address - Fax:478-454-1068
Practice Address - Street 1:385 MEADOW RIDGE DRIVE
Practice Address - Street 2:GREGORY M GRAHAM, DMD, LLC
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-8741
Practice Address - Country:US
Practice Address - Phone:478-452-0270
Practice Address - Fax:478-454-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN010029261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00289341BMedicaid