Provider Demographics
NPI:1972267284
Name:RAYTOWN DENTAL
Entity Type:Organization
Organization Name:RAYTOWN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-837-4010
Mailing Address - Street 1:8600 E 63RD ST
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133
Mailing Address - Country:US
Mailing Address - Phone:816-837-4010
Mailing Address - Fax:816-837-4011
Practice Address - Street 1:8600 E 63RD ST
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133
Practice Address - Country:US
Practice Address - Phone:816-837-4010
Practice Address - Fax:816-837-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400060672Medicaid