Provider Demographics
NPI:1669122370
Name:GRAHAM, ANASTASIA S (CRDH)
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:ANASTASIA
Other - Middle Name:S
Other - Last Name:PANKRATOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:BHC MCAS DENTAL, BLDG 598
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29904
Mailing Address - Country:US
Mailing Address - Phone:943-228-7512
Mailing Address - Fax:
Practice Address - Street 1:MCAS DENTAL, BLDG 598
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29904
Practice Address - Country:US
Practice Address - Phone:843-228-7512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11388124Q00000X
FLDH26758124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist