Healthcare Provider Details

I. General information

NPI: 1457374373
Provider Name (Legal Business Name): DON RICHARD GRAHAM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9710 WINTER GARDENS BLVD SUITE #C
LAKESIDE CA
92040-3866
US

IV. Provider business mailing address

9710 WINTER GARDENS BLVD SUITE #C
LAKESIDE CA
92040-3866
US

V. Phone/Fax

Practice location:
  • Phone: 619-443-8447
  • Fax: 619-443-5450
Mailing address:
  • Phone: 619-443-8447
  • Fax: 619-443-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21885
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: