Provider Demographics
NPI:1619009198
Name:VAN GENNIP, RAYMOND B (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:B
Last Name:VAN GENNIP
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8630 FENTON ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3806
Mailing Address - Country:US
Mailing Address - Phone:301-565-8030
Mailing Address - Fax:
Practice Address - Street 1:8630 FENTON ST
Practice Address - Street 2:SUITE 212
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3806
Practice Address - Country:US
Practice Address - Phone:301-565-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics