Provider Demographics
NPI:1063490639
Name:GRAHAM, EDITHANN JENNINGS (DMD)
Entity type:Individual
Prefix:DR
First Name:EDITHANN
Middle Name:JENNINGS
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:EDITH
Other - Middle Name:ANN
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1806 CABLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3103
Mailing Address - Country:US
Mailing Address - Phone:619-226-4784
Mailing Address - Fax:619-226-3027
Practice Address - Street 1:1806 CABLE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-3103
Practice Address - Country:US
Practice Address - Phone:619-226-4784
Practice Address - Fax:619-226-3027
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52531223P0300X
CACA566511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics