Healthcare Provider Details

I. General information

NPI: 1285999367
Provider Name (Legal Business Name): ELISE BURTON GRAHAM D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 LINCOLN RD SUITE 10
HATTIESBURG MS
39402-3036
US

IV. Provider business mailing address

4301 LINCOLN RD SUITE 10
HATTIESBURG MS
39402-3036
US

V. Phone/Fax

Practice location:
  • Phone: 601-582-2578
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3656-12
License Number StateMS
# 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: