Provider Demographics
NPI:1427377050
Name:GRAHAM, EDWARD THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:THOMAS
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 1:602 LINCOLN CTR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-2639
Mailing Address - Country:US
Mailing Address - Phone:209-477-4089
Mailing Address - Fax:209-477-6729
Practice Address - Street 1:602 LINCOLN CTR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2639
Practice Address - Country:US
Practice Address - Phone:209-477-4089
Practice Address - Fax:209-477-6729
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29808122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist