Provider Demographics
NPI:1013217579
Name:RODEO DENTAL SOUTHMOST PLLC
Entity Type:Organization
Organization Name:RODEO DENTAL SOUTHMOST PLLC
Other - Org Name:RODEO DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-653-9799
Mailing Address - Street 1:2950 SOUTHMOST RD
Mailing Address - Street 2:103
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-4787
Mailing Address - Country:US
Mailing Address - Phone:817-534-7325
Mailing Address - Fax:817-534-4429
Practice Address - Street 1:2950 SOUTHMOST RD
Practice Address - Street 2:103
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-4787
Practice Address - Country:US
Practice Address - Phone:817-534-7325
Practice Address - Fax:817-534-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23066122300000X
TX215271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty