Provider Demographics
NPI:1265652481
Name:GRAHAM, STEPHEN (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
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:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-0767
Mailing Address - Country:US
Mailing Address - Phone:928-567-1832
Mailing Address - Fax:928-567-6500
Practice Address - Street 1:1996 DOUGS PARK ROAD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322
Practice Address - Country:US
Practice Address - Phone:928-567-1832
Practice Address - Fax:928-567-6500
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD19951223P0221X
AZD43301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114736Medicaid
NMG2446Medicaid