Provider Demographics
NPI:1629132501
Name:RAVENS, MICHAEL ADAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ADAM
Last Name:RAVENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 557
Mailing Address - Street 2:BOX 3176
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3D DENTAL BATTALION
Practice Address - Street 2:UNIT 38450
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96604
Practice Address - Country:US
Practice Address - Phone:1617-848-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice