Provider Demographics
NPI:1104096817
Name:RAYGADA, SUSANA (DMD)
Entity type:Individual
Prefix:DR
First Name:SUSANA
Middle Name:
Last Name:RAYGADA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 LYNGATE CT
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1671
Mailing Address - Country:US
Mailing Address - Phone:703-323-1400
Mailing Address - Fax:703-426-0415
Practice Address - Street 1:5211 LYNGATE CT
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1671
Practice Address - Country:US
Practice Address - Phone:703-323-1400
Practice Address - Fax:703-426-0415
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014109541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice