Provider Demographics
NPI:1477857571
Name:RAYMUNDO DENTAL PRACTICE INC
Entity Type:Organization
Organization Name:RAYMUNDO DENTAL PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER, PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONALYN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RAYMUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-359-4595
Mailing Address - Street 1:170 E FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2569
Mailing Address - Country:US
Mailing Address - Phone:626-359-4595
Mailing Address - Fax:626-359-4596
Practice Address - Street 1:170 E FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2569
Practice Address - Country:US
Practice Address - Phone:626-359-4595
Practice Address - Fax:626-359-4596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40194-01Medicaid
CA833572OtherUNITED CONCORDIA PROVIDER