Provider Demographics
NPI:1225027923
Name:GRAHAM, GEORGE G JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:G
Last Name:GRAHAM
Suffix:JR
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 1:3424 S CULPEPPER CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3755
Mailing Address - Country:US
Mailing Address - Phone:417-889-4746
Mailing Address - Fax:417-889-1398
Practice Address - Street 1:3424 S CULPEPPER CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3755
Practice Address - Country:US
Practice Address - Phone:417-889-4746
Practice Address - Fax:417-889-1398
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO143681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice