Provider Demographics
NPI:1184276255
Name:GRAHAM, JYMIE (DDS)
Entity type:Individual
Prefix:DR
First Name:JYMIE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 PARNASSUS AVE # UB-10
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2208
Mailing Address - Country:US
Mailing Address - Phone:415-476-8226
Mailing Address - Fax:
Practice Address - Street 1:533 PARNASSUS AVE # UB-10
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2208
Practice Address - Country:US
Practice Address - Phone:415-476-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1057721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW202657765OtherAETNA