Provider Demographics
NPI:1245217074
Name:RAYMOND, MARK ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:RAYMOND
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:PO BOX 2214
Mailing Address - Street 2:
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-2214
Mailing Address - Country:US
Mailing Address - Phone:276-395-6632
Mailing Address - Fax:276-395-5601
Practice Address - Street 1:208 FRONT ST W
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230-3502
Practice Address - Country:US
Practice Address - Phone:276-395-6632
Practice Address - Fax:276-395-5601
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014107121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA146346OtherBLUE CROSS BLUE SHIELD
VA9179077Medicaid