MEDICARE: DR. RAFFY KOUYOUMDJIAN DMD

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	122300000X	Dentist	23066	TX
2	1223G0001X	General Practice Dentistry	23066	TX

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
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780705483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAFFY KOUYOUMDJIAN DMD

Provider Business Mailing Address
First Line	:	9090 SKILLMAN ST
Second Line	:	SUITE 200C
City	:	DALLAS
State	:	TX
Zip	:	75243-8259
Country	:	US
Telephone Number	:	214-342-5757
Fax Number	:	214-340-4868

Provider Business Practice Location Address
First Line	:	2482 JACKSBORO HWY
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76114-2201
Country	:	US
Telephone Number	:	817-626-4867
Fax Number	:	817-626-4866

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	10/25/2012

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