Healthcare Provider Details

I. General information

NPI: 1457022618
Provider Name (Legal Business Name): DAVID MATTHEW GRAHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 3RD AVE NE
CULLMAN AL
35055-2928
US

IV. Provider business mailing address

406 3RD AVE NE
CULLMAN AL
35055-2928
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-6418
  • Fax: 256-739-9529
Mailing address:
  • Phone: 256-739-6418
  • Fax: 256-739-9529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6226-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: