=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548850001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOBBY L RABER DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2021
-----------------------------------------------------
Last Update Date | 01/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7870 E FLORENTINE RD
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86314-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-589-4700
-----------------------------------------------------
Fax | 928-589-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 LORRAINE DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-4688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-848-4570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMIN
-----------------------------------------------------
Name | MR. MATT CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-308-0539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------