Provider Demographics
NPI:1235249228
Name:MAXWELL, RAYMOND MICHAEL (DDS, PS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:DDS, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-2108
Mailing Address - Country:US
Mailing Address - Phone:360-805-0900
Mailing Address - Fax:360-794-6891
Practice Address - Street 1:770 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2108
Practice Address - Country:US
Practice Address - Phone:360-805-0900
Practice Address - Fax:360-794-6891
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000064851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics