Provider Demographics
NPI:1346082450
Name:GRAHAM, CLARENCE DANTE
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:DANTE
Last Name:GRAHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4812
Mailing Address - Country:US
Mailing Address - Phone:920-382-2328
Mailing Address - Fax:
Practice Address - Street 1:660 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1010
Practice Address - Country:US
Practice Address - Phone:920-382-2328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program