Provider Demographics
NPI:1457899429
Name:PUTRUS, RAPHAEL R (DMD, MPH, MHA)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:R
Last Name:PUTRUS
Suffix:
Gender:M
Credentials:DMD, MPH, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 E 14 MILE RD STE 3/4
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4369
Mailing Address - Country:US
Mailing Address - Phone:586-999-9000
Mailing Address - Fax:586-999-8000
Practice Address - Street 1:4600 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4369
Practice Address - Country:US
Practice Address - Phone:248-798-6237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031029122300000X
MI29010221201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty