Provider Demographics
NPI:1811155674
Name:RAELYN N SUTTON DMD PC
Entity type:Organization
Organization Name:RAELYN N SUTTON DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAELYN
Authorized Official - Middle Name:NYLUND
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-476-9792
Mailing Address - Street 1:828 NE A ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526
Mailing Address - Country:US
Mailing Address - Phone:541-476-9792
Mailing Address - Fax:541-955-4512
Practice Address - Street 1:828 NE A ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-476-9792
Practice Address - Fax:541-955-4512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4986122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty