Provider Demographics
NPI:1780202937
Name:GRAHAM, KELLAN (DMD)
Entity Type:Individual
Prefix:
First Name:KELLAN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 SPRING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-7055
Mailing Address - Country:US
Mailing Address - Phone:386-365-2706
Mailing Address - Fax:
Practice Address - Street 1:131 MONTGOMERY XING
Practice Address - Street 2:
Practice Address - City:BISCOE
Practice Address - State:NC
Practice Address - Zip Code:27209-9592
Practice Address - Country:US
Practice Address - Phone:910-428-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist