Provider Demographics
NPI:1174829287
Name:RAIFFE, DAVID MARK (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARK
Last Name:RAIFFE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-3725
Mailing Address - Country:US
Mailing Address - Phone:330-395-3820
Mailing Address - Fax:
Practice Address - Street 1:916 KENMORE BLVD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44314-2113
Practice Address - Country:US
Practice Address - Phone:330-753-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH019625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0963631Medicaid