Provider Demographics
NPI:1568992816
Name:GRAHAM, CHARLENE ELISA
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:ELISA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15438 S ACUFF LN
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-3371
Mailing Address - Country:US
Mailing Address - Phone:913-317-6175
Mailing Address - Fax:
Practice Address - Street 1:407 S CLAIRBORNE RD STE 104
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1744
Practice Address - Country:US
Practice Address - Phone:913-648-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11395124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist