Provider Demographics
NPI:1194838532
Name:VICENTE, RAYMOND S (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:S
Last Name:VICENTE
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 1:7481 NORTHSIDE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420
Mailing Address - Country:US
Mailing Address - Phone:843-863-8634
Mailing Address - Fax:843-863-8242
Practice Address - Street 1:7481 NORTHSIDE DR
Practice Address - Street 2:SUITE A
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420
Practice Address - Country:US
Practice Address - Phone:843-863-8634
Practice Address - Fax:843-863-8242
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3976122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9568Medicaid