Provider Demographics
NPI:1881842169
Name:RAI, POONAM P (DDS)
Entity Type:Individual
Prefix:DR
First Name:POONAM
Middle Name:P
Last Name:RAI
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 1:585 GRACE LANE
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-632-9236
Mailing Address - Fax:
Practice Address - Street 1:550 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8160
Practice Address - Country:US
Practice Address - Phone:972-632-9236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57512122300000X
TX24352122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist