Provider Demographics
NPI:1306968359
Name:GRAHAM, JOHN (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E 900 S STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1281
Mailing Address - Country:US
Mailing Address - Phone:801-917-4746
Mailing Address - Fax:
Practice Address - Street 1:705 E 900 S STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-1281
Practice Address - Country:US
Practice Address - Phone:801-917-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT78916061223X0400X
AZ55091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics