Provider Demographics
NPI:1851626592
Name:GRAHAM, LESLEY ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:LESLEY
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:LESLEY
Other - Middle Name:ANN
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-0212
Mailing Address - Country:US
Mailing Address - Phone:360-478-2633
Mailing Address - Fax:360-373-2096
Practice Address - Street 1:616 6TH ST
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337-1420
Practice Address - Country:US
Practice Address - Phone:360-377-3776
Practice Address - Fax:360-373-2096
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600984001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1851626592Medicaid
WA5060330Medicaid