Provider Demographics
NPI:1396740247
Name:GRAHAM-FORTUNE, TAMMY ELIZABETH (DMD)
Entity type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:ELIZABETH
Last Name:GRAHAM-FORTUNE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:EDWARD
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:9001 GALENE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-1521
Mailing Address - Country:US
Mailing Address - Phone:502-267-8176
Mailing Address - Fax:502-267-8177
Practice Address - Street 1:9001 GALENE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1521
Practice Address - Country:US
Practice Address - Phone:502-267-8176
Practice Address - Fax:502-267-8177
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice