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General NPI Number Information
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NPI Number | 1396567095
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Entity Type | Organization
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Legal Business Name | RAYNALD L. DESAMEAU DMD PLLC III
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Dates
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Enumeration Date | 10/25/2024
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Last Update Date | 10/25/2024
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Provider Practice Location Address
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Address Line | 10460 PARK ROAD
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City | CHARLOTTE
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State | NC
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Zip | 28210
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Country | US
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Telephone | 704-540-5440
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Fax |
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Provider Business Mailing Address
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Address Line | 10460 PARK ROAD
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City | CHARLOTTE
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State | NC
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Zip | 28210
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | RAYNALD LEON DESAMEAU
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Credential | DMD
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Telephone | 912-332-3932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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