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General NPI Number Information
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NPI Number | 1568992816
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Entity Type | Individual
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Provider Name | CHARLENE ELISA GRAHAM
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Gender | Female
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Dates
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Enumeration Date | 06/19/2017
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Last Update Date | 06/19/2017
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Provider Practice Location Address
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Address Line | 407 S CLAIRBORNE RD STE 104
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City | OLATHE
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State | KS
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Zip | 66062-1744
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Country | US
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Telephone | 913-648-2266
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Fax |
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Provider Business Mailing Address
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Address Line | 15438 S ACUFF LN
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City | OLATHE
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State | KS
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Zip | 66062-3371
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Country | US
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Telephone | 913-317-6175
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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 | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 11395
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License Number State | KS
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