Healthcare Provider Details

I. General information

NPI: 1861194706
Provider Name (Legal Business Name): JOSH GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 ATLANTIC BLVD STE 7
NEPTUNE BEACH FL
32266-4001
US

IV. Provider business mailing address

1001 TEMPLE GRV
WINTER PARK FL
32789-2788
US

V. Phone/Fax

Practice location:
  • Phone: 407-401-4117
  • Fax:
Mailing address:
  • Phone: 407-401-4117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number28387
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901601892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: