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General NPI Number Information
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NPI Number | 1457899429
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Entity Type | Individual
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Provider Name | RAPHAEL R PUTRUS DMD, MPH, MHA
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Gender | Male
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Dates
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Enumeration Date | 02/09/2017
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Last Update Date | 09/08/2018
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Provider Practice Location Address
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Address Line | 4600 E 14 MILE RD
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City | WARREN
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State | MI
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Zip | 48092-4369
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Country | US
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Telephone | 248-798-6237
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Fax |
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Provider Business Mailing Address
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Address Line | 4600 E 14 MILE RD STE 3/4
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City | WARREN
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State | MI
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Zip | 48092-4369
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Country | US
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Telephone | 586-999-9000
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Fax | 586-999-8000
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019031029
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 2901022120
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License Number State | MI
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