Provider Demographics
NPI:1225289598
Name:GRAHAM, MICHELLE ANTONIA (DMD, MPH, DMSC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANTONIA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DMD, MPH, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 W SOVEREIGN PATH
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-8071
Mailing Address - Country:US
Mailing Address - Phone:352-249-9258
Mailing Address - Fax:352-249-9262
Practice Address - Street 1:2804 W MARC KNIGHTON CT
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-6300
Practice Address - Country:US
Practice Address - Phone:352-527-0068
Practice Address - Fax:352-527-8858
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15164122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN15164OtherLICENSE NUMBER