Provider Demographics
NPI:1396029781
Name:RODEO DENTAL PHARR PLLC
Entity Type:Organization
Organization Name:RODEO DENTAL PHARR PLLC
Other - Org Name:RODEO DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-653-9799
Mailing Address - Street 1:1300 SOUTH CAGE BLVD.
Mailing Address - Street 2:STE. K
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577
Mailing Address - Country:US
Mailing Address - Phone:817-624-6677
Mailing Address - Fax:
Practice Address - Street 1:1300 SOUTH CAGE BLVD.
Practice Address - Street 2:STE. K
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577
Practice Address - Country:US
Practice Address - Phone:817-624-6677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23066122300000X
TX241331223G0001X
TX215271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty