Provider Demographics
NPI:1023033255
Name:DEAN, RAYMOND J (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:DEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 W FRONT ST STE A
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7760
Mailing Address - Country:US
Mailing Address - Phone:231-935-0625
Mailing Address - Fax:231-935-0626
Practice Address - Street 1:3643 W FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7760
Practice Address - Country:US
Practice Address - Phone:231-935-0620
Practice Address - Fax:231-935-0626
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRD07707207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRD072707OtherMICHIGAN LIC#
MIH53601Medicare UPIN