=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457581217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER H RAE D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2009
-----------------------------------------------------
Last Update Date | 12/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 VICTORIA COMMONS BLVD
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-624-7658
-----------------------------------------------------
Fax | 386-873-4625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1431 ORANGE CAMP RD SUITE 108
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724-7768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-624-7658
-----------------------------------------------------
Fax | 386-873-4625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN18823
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------