Healthcare Provider Details

I. General information

NPI: 1003638719
Provider Name (Legal Business Name): RAYNALD L. DESAMEAU DMD PLLC IV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10460 PARK RD
CHARLOTTE NC
28210
US

IV. Provider business mailing address

10460 PARK RD
CHARLOTTE NC
28210
US

V. Phone/Fax

Practice location:
  • Phone: 704-540-5440
  • Fax:
Mailing address:
  • Phone: 704-540-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. RAYNALD LEON DESAMEAU
Title or Position: OWNER/MEMBER
Credential: DMD
Phone: 912-332-3932