Provider Demographics
NPI:1184820490
Name:GRAHAM, VIVIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
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 1:377 JERSEY AVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-4393
Mailing Address - Country:US
Mailing Address - Phone:201-369-9080
Mailing Address - Fax:
Practice Address - Street 1:377 JERSEY AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4393
Practice Address - Country:US
Practice Address - Phone:201-369-9080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-23
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052417122300000X
NJ22DI02330600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist