Healthcare Provider Details

I. General information

NPI: 1952508137
Provider Name (Legal Business Name): FRASER HEARD GRAHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15321 SAN PEDRO AVE SUITE 103
SAN ANTONIO TX
78232-3700
US

IV. Provider business mailing address

15321 SAN PEDRO AVE SUITE 103
SAN ANTONIO TX
78232-3700
US

V. Phone/Fax

Practice location:
  • Phone: 210-654-7878
  • Fax: 210-402-0410
Mailing address:
  • Phone: 210-654-7878
  • Fax: 210-402-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number11750
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: