MEDICARE: DR. EDITHANN JENNINGS GRAHAM DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	5253	AZ
2	1223P0300X	Periodontics	CA56651	CA

General Provider Information

NPI Number	:	1063490639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDITHANN JENNINGS GRAHAM DMD

Provider Business Mailing Address
First Line	:	1806 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3103
Country	:	US
Telephone Number	:	619-226-4784
Fax Number	:	619-226-3027

Provider Business Practice Location Address
First Line	:	1806 CABLE ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3103
Country	:	US
Telephone Number	:	619-226-4784
Fax Number	:	619-226-3027

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/17/2009

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