MEDICARE: RODEO LAREDO DENTAL & ORTHODONTICS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548611452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RODEO LAREDO DENTAL & ORTHODONTICS, PLLC

Provider Business Mailing Address
First Line	:	910 GUADALUPE STREET, SUITE A
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78040-5280
Country	:	US
Telephone Number	:	817-529-8151
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 GUADALUPE ST STE A
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78040-5280
Country	:	US
Telephone Number	:	817-529-8151
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAFFY KOUYOUMDJIAN
Credential	:	DMD
Telephone Number	:	972-814-2708

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	02/20/2017

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Directions to “RODEO LAREDO DENTAL & ORTHODONTICS, PLLC ” Practice Location

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