Provider Demographics
NPI:1336570654
Name:R. B. BRAIDFOOT DMD PLLC
Entity type:Organization
Organization Name:R. B. BRAIDFOOT DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST, OWNE/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:BRAIDFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-566-6383
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:C-626
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:672-566-6383
Mailing Address - Fax:972-566-3847
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:C-626
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:672-566-6383
Practice Address - Fax:972-566-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX236661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty