Provider Demographics
NPI:1730270257
Name:RAYMOND, DOMINIC JOHN II (DDS)
Entity type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:JOHN
Last Name:RAYMOND
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:56 MILEGROUND RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3803
Mailing Address - Country:US
Mailing Address - Phone:304-296-2273
Mailing Address - Fax:304-296-0825
Practice Address - Street 1:56 MILEGROUND RD
Practice Address - Street 2:SUITE A
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3803
Practice Address - Country:US
Practice Address - Phone:304-296-2273
Practice Address - Fax:304-296-0825
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV27031223G0001X
PADS023559L1223G0001X
FLDN 103801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133055000Medicaid