Provider Demographics
NPI:1447980636
Name:GRAHAM, JARRED AUGUSTUS (DDS)
Entity type:Individual
Prefix:DR
First Name:JARRED
Middle Name:AUGUSTUS
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4156 KIMLIE CV
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-1031
Mailing Address - Country:US
Mailing Address - Phone:404-454-1889
Mailing Address - Fax:
Practice Address - Street 1:1227 ROCKBRIDGE RD STE 300
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3065
Practice Address - Country:US
Practice Address - Phone:770-799-0349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN1228681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program