Provider Demographics
NPI:1790996155
Name:RAVERA, ROBERT WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WARREN
Last Name:RAVERA
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 1:1401 AVOCADO AVE
Mailing Address - Street 2:#406
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-644-0598
Mailing Address - Fax:949-644-2485
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:#406
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-644-0598
Practice Address - Fax:949-644-2485
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA189091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice