Provider Demographics
NPI:1780705483
Name:KOUYOUMDJIAN, RAFFY (DMD)
Entity type:Individual
Prefix:DR
First Name:RAFFY
Middle Name:
Last Name:KOUYOUMDJIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9090 SKILLMAN ST
Mailing Address - Street 2:SUITE 200C
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-8259
Mailing Address - Country:US
Mailing Address - Phone:214-342-5757
Mailing Address - Fax:214-340-4868
Practice Address - Street 1:2482 JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-2201
Practice Address - Country:US
Practice Address - Phone:817-626-4867
Practice Address - Fax:817-626-4866
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23066122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1479404-03Medicaid
TX1479404-06Medicaid
TX1479404-08Medicaid
TX1479404-04Medicaid
TX1479404-09Medicaid
TX1479404-12Medicaid
TX1479404-07Medicaid
TX1479404-11Medicaid
TX1479404-10Medicaid
TX1479404-05Medicaid
TX1824195-02Medicaid
TX1479404-01Medicaid