Provider Demographics
NPI:1255591384
Name:GRAHAM, BRAD AUSTIN (DMD)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:AUSTIN
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 1:1857 TUCKER WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:40104
Mailing Address - Country:US
Mailing Address - Phone:270-781-2952
Mailing Address - Fax:270-797-0977
Practice Address - Street 1:1857 TUCKER WAY
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:40104
Practice Address - Country:US
Practice Address - Phone:270-781-2952
Practice Address - Fax:270-793-0977
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY8362122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist