Provider Demographics
NPI:1962623363
Name:GRAHAM, STEPHANIE ELAINE (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ELAINE
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 1:530 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1816
Mailing Address - Country:US
Mailing Address - Phone:618-443-4721
Mailing Address - Fax:618-443-4722
Practice Address - Street 1:530 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1816
Practice Address - Country:US
Practice Address - Phone:618-443-4721
Practice Address - Fax:618-443-4722
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL958147OtherUNITED CONCORDIA