Provider Demographics
NPI:1972513208
Name:WM GRAHAM GARDNER DDS PC
Entity Type:Organization
Organization Name:WM GRAHAM GARDNER DDS PC
Other - Org Name:RICHARD A LETTEW DDS LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GRAHAM
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-282-6436
Mailing Address - Street 1:1206 WILLOW LAWN DRIVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1409
Mailing Address - Country:US
Mailing Address - Phone:804-282-6436
Mailing Address - Fax:804-282-8297
Practice Address - Street 1:1206 WILLOW LAWN DRIVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1409
Practice Address - Country:US
Practice Address - Phone:804-282-6436
Practice Address - Fax:804-282-8297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010089261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9178639Medicaid