Healthcare Provider Details

I. General information

NPI: 1942645585
Provider Name (Legal Business Name): DIANA ELAINE GRAHAM RDH, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 CUTLER AVE NE
ALBUQUERQUE NM
87110-3935
US

IV. Provider business mailing address

4400 CUTLER AVE NE
ALBUQUERQUE NM
87110-3935
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-1234
  • Fax:
Mailing address:
  • Phone: 505-881-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3207
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: