Provider Demographics
NPI:1679667760
Name:WINTERS, RAYMOND CLYDE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:CLYDE
Last Name:WINTERS
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 1:1519 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5249
Mailing Address - Country:US
Mailing Address - Phone:360-570-0327
Mailing Address - Fax:
Practice Address - Street 1:4408 PACIFIC AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1119
Practice Address - Country:US
Practice Address - Phone:360-438-8299
Practice Address - Fax:360-438-1399
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000041471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5358403Medicaid
WA823455OtherUNITED CONCORDIA