Provider Demographics
NPI:1275684383
Name:RAPHAEL, DAVID COLEMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:COLEMAN
Last Name:RAPHAEL
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 1:4432 CONLIN ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2146
Mailing Address - Country:US
Mailing Address - Phone:504-888-9204
Mailing Address - Fax:504-888-4224
Practice Address - Street 1:4432 CONLIN ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2146
Practice Address - Country:US
Practice Address - Phone:504-888-9204
Practice Address - Fax:504-888-4224
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1820776Medicaid