MEDICARE: RAFAELA CRISTINA COSTA CARLOS

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	DS045345	PA

General Provider Information

NPI Number	:	1093427932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAFAELA CRISTINA COSTA CARLOS

Provider Business Mailing Address
First Line	:	353 DELMAR ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-4505
Country	:	US
Telephone Number	:	917-855-1036
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 WINDING DR STE 105
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-2907
Country	:	US
Telephone Number	:	215-402-2471
Fax Number	:

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

Provider Enumeration Date	:	12/22/2022
Last Update Date	:	07/23/2025

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