=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013217579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RODEO DENTAL SOUTHMOST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 10/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2950 SOUTHMOST RD 103
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78521-4787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-534-7325
-----------------------------------------------------
Fax | 817-534-4429
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2950 SOUTHMOST RD 103
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78521-4787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-534-7325
-----------------------------------------------------
Fax | 817-534-4429
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAFFY KOUYOUMDJIAN
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 818-653-9799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 21527
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 23066
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------