Provider Demographics
NPI:1356503700
Name:GRAHAM, JEREMY GORDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:GORDON
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 1:78361 HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:LA
Mailing Address - Zip Code:70437-3320
Mailing Address - Country:US
Mailing Address - Phone:985-796-9345
Mailing Address - Fax:985-796-9345
Practice Address - Street 1:78361 HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:LA
Practice Address - Zip Code:70437-3320
Practice Address - Country:US
Practice Address - Phone:985-796-9345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice