Provider Demographics
NPI:1477013233
Name:HUNTLEY, RAPHAEL (DDS, PHD)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:HUNTLEY
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1956
Mailing Address - Country:US
Mailing Address - Phone:916-233-6352
Mailing Address - Fax:
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-520-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADR60949163204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program