Basic Information
| Provider Information | |||||||||
| NPI: | 1780705483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUYOUMDJIAN | ||||||||
| FirstName: | RAFFY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9090 SKILLMAN ST | ||||||||
| Address2: | SUITE 200C | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752438259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143425757 | ||||||||
| FaxNumber: | 2143404868 | ||||||||
| Practice Location | |||||||||
| Address1: | 2482 JACKSBORO HWY | ||||||||
| Address2: | |||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761142201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176264867 | ||||||||
| FaxNumber: | 8176264866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 23066 | TX | Y | Dental Providers | Dentist | 1223G0001X | 23066 | TX | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1479404-03 | 05 | TX | MEDICAID | 1479404-06 | 05 | TX | MEDICAID | 1479404-08 | 05 | TX | MEDICAID | 1479404-04 | 05 | TX | MEDICAID | 1479404-09 | 05 | TX | MEDICAID | 1479404-12 | 05 | TX | MEDICAID | 1479404-07 | 05 | TX | MEDICAID | 1479404-11 | 05 | TX | MEDICAID | 1479404-10 | 05 | TX | MEDICAID | 1479404-05 | 05 | TX | MEDICAID | 1824195-02 | 05 | TX | MEDICAID | 1479404-01 | 05 | TX | MEDICAID |