Provider Demographics
NPI:1285999367
Name:GRAHAM, ELISE BURTON (DMD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:BURTON
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 LINCOLN RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4301 LINCOLN RD
Practice Address - Street 2:SUITE 10
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3036
Practice Address - Country:US
Practice Address - Phone:601-582-2578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS3656-121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program