Provider Demographics
NPI:1548330418
Name:MACK, RAYMOND BRENT (DDS)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:BRENT
Last Name:MACK
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 1:9712 BELAIR RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1112
Mailing Address - Country:US
Mailing Address - Phone:410-256-1715
Mailing Address - Fax:410-256-1765
Practice Address - Street 1:9712 BELAIR RD STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-1112
Practice Address - Country:US
Practice Address - Phone:410-256-1715
Practice Address - Fax:410-256-1765
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD6437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6437OtherLICENSE #