Healthcare Provider Details

I. General information

NPI: 1053302216
Provider Name (Legal Business Name): JAMES BRADLEY GRAHAM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1067 TWINING DR
BARKSDALE AFB LA
71110-2486
US

IV. Provider business mailing address

3218 STOCKWELL RD
BOSSIER CITY LA
71111-5751
US

V. Phone/Fax

Practice location:
  • Phone: 318-456-6568
  • Fax: 318-456-6656
Mailing address:
  • Phone: 318-752-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2890
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: