Provider Demographics
NPI:1679660492
Name:RALEIGH DENTAL CLINIC
Entity Type:Organization
Organization Name:RALEIGH DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-782-9206
Mailing Address - Street 1:PO BOX 595
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-0595
Mailing Address - Country:US
Mailing Address - Phone:601-782-9206
Mailing Address - Fax:
Practice Address - Street 1:207 SYLVARENA AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153
Practice Address - Country:US
Practice Address - Phone:601-782-9206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1219-661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015677Medicaid