Provider Demographics
NPI:1053354373
Name:CRISIO, RAYMOND ANTHONY (DMD)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:ANTHONY
Last Name:CRISIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:62222
Mailing Address - Country:US
Mailing Address - Phone:618-632-6100
Mailing Address - Fax:618-632-6156
Practice Address - Street 1:4933 BENCHMARK CENTRE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-632-6100
Practice Address - Fax:618-632-6156
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019233801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL109696Medicaid