Healthcare Provider Details

I. General information

NPI: 1447980636
Provider Name (Legal Business Name): JARRED AUGUSTUS GRAHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 ROCKBRIDGE RD STE 300
STONE MOUNTAIN GA
30087-3065
US

IV. Provider business mailing address

4156 KIMLIE CV
DECATUR GA
30035-1031
US

V. Phone/Fax

Practice location:
  • Phone: 770-799-0349
  • Fax:
Mailing address:
  • Phone: 404-454-1889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN122868
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: