Provider Demographics
NPI:1821106394
Name:GRAHAM, JEFFREY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
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 1:7517 CAMERON ROAD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752
Mailing Address - Country:US
Mailing Address - Phone:512-328-6763
Mailing Address - Fax:512-328-7511
Practice Address - Street 1:10160 SUPERIOR WAY
Practice Address - Street 2:
Practice Address - City:AMELIA COURT HOUSE
Practice Address - State:VA
Practice Address - Zip Code:23002-4744
Practice Address - Country:US
Practice Address - Phone:804-561-4379
Practice Address - Fax:804-561-2019
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21390122300000X
VA04014115281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist