Provider Demographics
NPI:1710534904
Name:DESAMEAU, RAYNALD LEON (DMD)
Entity Type:Individual
Prefix:
First Name:RAYNALD
Middle Name:LEON
Last Name:DESAMEAU
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 1:10700 KETTERING DR STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3771
Mailing Address - Country:US
Mailing Address - Phone:704-540-5440
Mailing Address - Fax:704-540-5441
Practice Address - Street 1:401 S SHARON AMITY RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2848
Practice Address - Country:US
Practice Address - Phone:704-365-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11583122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist