MEDICARE: DR. RANDY GORDON RAETZ DDS

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	045887	NY

General Provider Information

NPI Number	:	1811990807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY GORDON RAETZ DDS

Provider Business Mailing Address
First Line	:	2273 S CLINTON AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-2662
Country	:	US
Telephone Number	:	585-473-1550
Fax Number	:	585-473-1552

Provider Business Practice Location Address
First Line	:	2273 S CLINTON AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-2662
Country	:	US
Telephone Number	:	585-473-1550
Fax Number	:	585-473-1552

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/02/2011

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