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General NPI Number Information
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NPI Number | 1457528267
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Entity Type | Individual
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Provider Name | ANTHONY GRAHAM
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Gender | Male
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Dates
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Enumeration Date | 05/12/2008
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Last Update Date | 05/12/2008
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Provider Practice Location Address
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Address Line | 2500 W LAKE MARY BLVD SUITE- 106
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City | LAKE MARY
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State | FL
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Zip | 32746-3501
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Country | US
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Telephone | 407-328-6411
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Fax |
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Provider Business Mailing Address
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Address Line | 2502 N ROCKY POINT DR SUITE 1000- CREDENTIALING
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City | TAMPA
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State | FL
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Zip | 33607-1421
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Country | US
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Telephone | 813-288-1999
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN15163
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License Number State | FL
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