Provider Demographics
NPI:1710117593
Name:RAYNHAM FAMILY DENTAL, INC.
Entity Type:Organization
Organization Name:RAYNHAM FAMILY DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANG
Authorized Official - Middle Name:K
Authorized Official - Last Name:BAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-824-7211
Mailing Address - Street 1:302 BROADWAY UNIT 10
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1439
Mailing Address - Country:US
Mailing Address - Phone:508-824-7211
Mailing Address - Fax:508-880-0045
Practice Address - Street 1:302 BROADWAY UNIT 10
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1439
Practice Address - Country:US
Practice Address - Phone:508-824-7211
Practice Address - Fax:508-880-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty