Provider Demographics
NPI:1417526294
Name:PEORIA ST. DENTAL AND ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:PEORIA ST. DENTAL AND ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:100 E 15TH ST STE 520
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-6566
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:
Practice Address - Street 1:757 PEORIA ST STE D
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8262
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:817-928-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty