Healthcare Provider Details

I. General information

NPI: 1699815407
Provider Name (Legal Business Name): GAR S GRAHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W PERIMETER RD STE A-1
ANDREWS AFB MD
20762-6601
US

IV. Provider business mailing address

1050 W PERIMETER RD STE A-1
ANDREWS AFB MD
20762-6601
US

V. Phone/Fax

Practice location:
  • Phone: 240-857-9639
  • Fax: 240-857-8650
Mailing address:
  • Phone: 240-857-9639
  • Fax: 240-857-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8193
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: