Provider Demographics
NPI:1215945951
Name:FONSECA, RAYMOND JANUARIO (DMD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JANUARIO
Last Name:FONSECA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ROCKCLIFF PL
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4510
Mailing Address - Country:US
Mailing Address - Phone:828-255-7781
Mailing Address - Fax:
Practice Address - Street 1:5 ROCKCLIFF PL
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4510
Practice Address - Country:US
Practice Address - Phone:828-255-7781
Practice Address - Fax:828-258-3770
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89902UTMedicaid
NC3375OtherN.C. STATE DENTAL BOARD
2410164Medicare ID - Type Unspecified
NC89902UTMedicaid