Provider Demographics
NPI:1013250026
Name:WARREN DENTAL GROUP, DAVID M RAIFFE, DDS, MBA, INC
Entity Type:Organization
Organization Name:WARREN DENTAL GROUP, DAVID M RAIFFE, DDS, MBA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-395-3820
Mailing Address - Street 1:7601 ROYAL PORTRUSH DR
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-5256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019 N PARK AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3725
Practice Address - Country:US
Practice Address - Phone:330-395-3820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0196251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0963631Medicaid