1144203688 NPI number — DR. KATHERINE MARIE GRAHAM D.M.D.

Table of content: DR. KATHERINE MARIE GRAHAM D.M.D. (NPI 1144203688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144203688 NPI number — DR. KATHERINE MARIE GRAHAM D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
KATHERINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144203688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10912 NW LUSANNE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97229-6172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-671-9333
Provider Business Mailing Address Fax Number:
503-626-8366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12672 NW BARNES RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97229-6016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-644-9915
Provider Business Practice Location Address Fax Number:
503-350-1275
Provider Enumeration Date:
11/29/2005

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:  D6791 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0005116600 . This is a "AETNA PIN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 046545 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 037212000 . This is a "REGENCE BC/BS PROV ID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 000006791OR . This is a "DELTA DENTAL PAYEE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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