Provider Demographics
NPI:1336878693
Name:GRAHAM, JUSTIN THOMAS (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:THOMAS
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 ASHLEY OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6404
Mailing Address - Country:US
Mailing Address - Phone:813-991-5300
Mailing Address - Fax:888-520-4252
Practice Address - Street 1:2242 ASHLEY OAKS CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6404
Practice Address - Country:US
Practice Address - Phone:813-991-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN270001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121860900Medicaid