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General NPI Number Information
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NPI Number | 1265782361
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL SPECIALISTS PLLC
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Dates
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Enumeration Date | 09/16/2012
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Last Update Date | 09/16/2012
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Provider Practice Location Address
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Address Line | 213 BULIFANTS BLVD STE B
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City | WILLIAMSBURG
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State | VA
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Zip | 23188-5733
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Country | US
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Telephone | 866-977-4787
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Fax |
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Provider Business Mailing Address
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Address Line | 213 BULIFANTS BLVD STE B
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City | WILLIAMSBURG
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State | VA
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Zip | 23188-5733
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Country | US
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Telephone | 866-977-4787
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Fax |
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Authorized Official
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Title or Position | OWNER/PEDIATRIC DENTIST
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Name | DR. RANA DENISE GRAHAM-MONTAQE
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Credential | DDS
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Telephone | 866-977-4787
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 0401411505
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License Number State | VA
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