Provider Demographics
NPI:1619024221
Name:LA VIGNE, RAYMOND E (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:E
Last Name:LA VIGNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 N 1ST BANK DR
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8111
Mailing Address - Country:US
Mailing Address - Phone:847-359-1292
Mailing Address - Fax:847-359-1296
Practice Address - Street 1:637 N 1ST BANK DR
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8111
Practice Address - Country:US
Practice Address - Phone:847-359-1292
Practice Address - Fax:847-359-1296
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19161181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice