Provider Demographics
NPI:1831280809
Name:KANEVSKY, RAISA K (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAISA
Middle Name:K
Last Name:KANEVSKY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12570 BROOKHURST STREET
Mailing Address - Street 2:SUITE # 2 PRIMARY DENTAL CARE
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840
Mailing Address - Country:US
Mailing Address - Phone:714-537-5700
Mailing Address - Fax:714-537-5701
Practice Address - Street 1:12570 BROOKHURST STREET
Practice Address - Street 2:SUITE # 2 PRIMARY DENTAL CARE
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840
Practice Address - Country:US
Practice Address - Phone:714-537-5700
Practice Address - Fax:714-537-5701
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28578122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2857801Medicare ID - Type Unspecified