Provider Demographics
NPI:1720520794
Name:PEDIATRIC DENTAL SPECIALISTS OF HAMPTON
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALISTS OF HAMPTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RANA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRAHAM-MONTAQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-640-8545
Mailing Address - Street 1:213 BULIFANTS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5733
Mailing Address - Country:US
Mailing Address - Phone:757-903-4525
Mailing Address - Fax:
Practice Address - Street 1:2111 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2576
Practice Address - Country:US
Practice Address - Phone:757-903-4525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411505261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3061719Medicaid