=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700029253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAYTOWN DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2009
-----------------------------------------------------
Last Update Date | 04/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9600 E HIGHWAY 350
-----------------------------------------------------
City | RAYTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64133-6513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-356-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9600 E HIGHWAY 350
-----------------------------------------------------
City | RAYTOWN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64133-6513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-356-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MATHEW DRAPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-356-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------