=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023234325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS. GRAHAM AND FORTUNE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9001 GALENE DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40299-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-267-8176
-----------------------------------------------------
Fax | 502-267-8177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9001 GALENE DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40299-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-267-8176
-----------------------------------------------------
Fax | 502-267-8177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. TAMMY ELIZABETH GRAHAM-FORTUNE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 502-267-8176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------