1851626592 NPI number — DR. LESLEY ANN GRAHAM DMD

Table of content: DR. LESLEY ANN GRAHAM DMD (NPI 1851626592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851626592 NPI number — DR. LESLEY ANN GRAHAM DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
LESLEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KING
Provider Other First Name:
LESLEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851626592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 960
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98337-0212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-478-2633
Provider Business Mailing Address Fax Number:
360-373-2096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98337-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-377-3776
Provider Business Practice Location Address Fax Number:
360-373-2096
Provider Enumeration Date:
10/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DE60098400 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1851626592 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5060330 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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