Healthcare Provider Details

I. General information

NPI: 1821106394
Provider Name (Legal Business Name): JEFFREY SCOTT GRAHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10160 SUPERIOR WAY
AMELIA COURT HOUSE VA
23002-4744
US

IV. Provider business mailing address

7517 CAMERON ROAD SUITE 107
AUSTIN TX
78752
US

V. Phone/Fax

Practice location:
  • Phone: 804-561-4379
  • Fax: 804-561-2019
Mailing address:
  • Phone: 512-328-6763
  • Fax: 512-328-7511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number21390
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401411528
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: