Healthcare Provider Details

I. General information

NPI: 1750997110
Provider Name (Legal Business Name): WILLIAM JAMES GRAHAM IV DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG B-6837 NORMANDY DR
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

130 PINE BRANCH CT
SOUTHERN PINES NC
28387-4974
US

V. Phone/Fax

Practice location:
  • Phone: 910-396-2607
  • Fax:
Mailing address:
  • Phone: 609-501-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12021
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12021
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: