Provider Demographics
NPI:1538606595
Name:RAYMONDVILLE DENTAL
Entity type:Organization
Organization Name:RAYMONDVILLE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:956-699-3999
Mailing Address - Street 1:957 E HIDALGO AVE
Mailing Address - Street 2:STE. # B2
Mailing Address - City:RAYMONDVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78580-4149
Mailing Address - Country:US
Mailing Address - Phone:956-699-3999
Mailing Address - Fax:956-699-3901
Practice Address - Street 1:957 E HIDALGO AVE
Practice Address - Street 2:STE. # B2
Practice Address - City:RAYMONDVILLE
Practice Address - State:TX
Practice Address - Zip Code:78580-4149
Practice Address - Country:US
Practice Address - Phone:956-699-3999
Practice Address - Fax:956-699-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX301771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty