Provider Demographics
NPI:1912173899
Name:TREVISAN, RAYMOND WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:WALTER
Last Name:TREVISAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 OLD HOOK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3248
Mailing Address - Country:US
Mailing Address - Phone:201-358-0110
Mailing Address - Fax:201-722-9441
Practice Address - Street 1:354 OLD HOOK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3248
Practice Address - Country:US
Practice Address - Phone:201-358-0110
Practice Address - Fax:201-722-9441
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01428200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist