Healthcare Provider Details

I. General information

NPI: 1982976007
Provider Name (Legal Business Name): GRAHAM FAMILY DENTAL CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2012
Last Update Date: 02/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 W PLYMOUTH AVE
DELAND FL
32720-3200
US

IV. Provider business mailing address

646 W PLYMOUTH AVE
DELAND FL
32720-3200
US

V. Phone/Fax

Practice location:
  • Phone: 386-740-8282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IVAN GRAHAM
Title or Position: PRES
Credential: DDS
Phone: 386-740-8282