Provider Demographics
NPI:1427709682
Name:WV PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:WV PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IIAYA
Authorized Official - Middle Name:RAMANAN
Authorized Official - Last Name:RAJAGOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:BDS
Authorized Official - Phone:205-249-6175
Mailing Address - Street 1:1004 SUSHRUTA DR STE D
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-8801
Mailing Address - Country:US
Mailing Address - Phone:205-249-6175
Mailing Address - Fax:
Practice Address - Street 1:1004 SUSHRUTA DR STE D
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-8801
Practice Address - Country:US
Practice Address - Phone:205-249-6175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty