Provider Demographics
NPI:1326140708
Name:GRAHAM, JOHN ROBERTS (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERTS
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 1:50 PLAZA WAY
Mailing Address - Street 2:STE G
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-427-4778
Mailing Address - Fax:770-427-7402
Practice Address - Street 1:50 PLAZA WAY
Practice Address - Street 2:STE G
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-427-4778
Practice Address - Fax:770-427-7402
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA83491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2041988Medicaid