Provider Demographics
NPI:1528350782
Name:RODEO DENTAL SAN BENITO, PLLC
Entity type:Organization
Organization Name:RODEO DENTAL SAN BENITO, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:100 E. 15TH ST.
Mailing Address - Street 2:SUITE 520
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-6566
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:817-928-1681
Practice Address - Street 1:1141 US BUSINESS 77
Practice Address - Street 2:SUITE G
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-4376
Practice Address - Country:US
Practice Address - Phone:956-361-3377
Practice Address - Fax:817-928-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty