Provider Demographics
NPI:1225259344
Name:GRAHAM, STEPHEN DUANE SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DUANE
Last Name:GRAHAM
Suffix:SR
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:P.O. BOX 24475
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-4475
Mailing Address - Country:US
Mailing Address - Phone:423-595-1950
Mailing Address - Fax:
Practice Address - Street 1:1602 SOUTH HOLTZCLAW AVENUE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-698-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TND.S. 42181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0107735OtherBLUECROSSBLUESHIELD