Provider Demographics
NPI:1629535463
Name:RAGAIE, MONA M
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:M
Last Name:RAGAIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MARIOLYN WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-1625
Mailing Address - Country:US
Mailing Address - Phone:916-607-8708
Mailing Address - Fax:
Practice Address - Street 1:5500 MARIOLYN WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-1625
Practice Address - Country:US
Practice Address - Phone:916-607-8708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1033961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice