Healthcare Provider Details

I. General information

NPI: 1215076534
Provider Name (Legal Business Name): RAYMOND E. CARPENTER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 GENESEE AVE STE 207
SAN DIEGO CA
92117-4900
US

IV. Provider business mailing address

4320 GENESEE AVE STE 207
SAN DIEGO CA
92117-4900
US

V. Phone/Fax

Practice location:
  • Phone: 858-277-3910
  • Fax: 858-277-3258
Mailing address:
  • Phone: 858-277-3910
  • Fax: 858-277-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number25869
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number25869
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number25869
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: