Provider Demographics
NPI:1245395375
Name:DYSAS, RAYMOND J (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:DYSAS
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 1:1877 S MAPLE
Mailing Address - Street 2:#290
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324
Mailing Address - Country:US
Mailing Address - Phone:937-879-7990
Mailing Address - Fax:937-879-7991
Practice Address - Street 1:1877 S MAPLE
Practice Address - Street 2:#290
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324
Practice Address - Country:US
Practice Address - Phone:937-879-7990
Practice Address - Fax:937-879-7991
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30015568122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist