Provider Demographics
NPI:1881667053
Name:RECORD, RISA MAREE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RISA
Middle Name:MAREE
Last Name:RECORD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:RISA
Other - Middle Name:MAREE
Other - Last Name:POORTVLIET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:162 COUNTY ROAD 294
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-8436
Mailing Address - Country:US
Mailing Address - Phone:940-612-2916
Mailing Address - Fax:
Practice Address - Street 1:618 DENTAL COMPANY (AS)
Practice Address - Street 2:UNIT #15662 BLDG. S137 TEXAS AVENUE
Practice Address - City:CAMP CARROLL
Practice Address - State:APO AP
Practice Address - Zip Code:96260-5662
Practice Address - Country:KR
Practice Address - Phone:352-765-7185
Practice Address - Fax:352-765-7188
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBR92943531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196626OtherAGD/TAGD NUMBER
TXBR9294353OtherDEA NUMBER