Provider Demographics
NPI:1295822989
Name:LORETTA PROSSER GRAHAM, DDS, PC
Entity Type:Organization
Organization Name:LORETTA PROSSER GRAHAM, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-886-9169
Mailing Address - Street 1:15410 WARWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-1576
Mailing Address - Country:US
Mailing Address - Phone:757-886-9169
Mailing Address - Fax:757-874-8892
Practice Address - Street 1:15410 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-1576
Practice Address - Country:US
Practice Address - Phone:757-886-9169
Practice Address - Fax:757-874-8892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty