Provider Demographics
NPI:1073503991
Name:RAYMOND, GEORGE FREDERICK III (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:FREDERICK
Last Name:RAYMOND
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:289 E 149TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5601
Mailing Address - Country:US
Mailing Address - Phone:718-742-7400
Mailing Address - Fax:914-243-5821
Practice Address - Street 1:289 E 149TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5601
Practice Address - Country:US
Practice Address - Phone:718-742-7400
Practice Address - Fax:914-243-5821
Is Sole Proprietor?:No
Enumeration Date:2005-10-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0504321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02439307Medicaid