Healthcare Provider Details

I. General information

NPI: 1497764286
Provider Name (Legal Business Name): RAFAEL CARABALLO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402 LANDSTUHL DENTAL ACTIVITY, CREDENTIALS OFFICE
APO AE
09180
US

IV. Provider business mailing address

CMR 402 LANDSTUHL DENTAL ACTIVITY, CREDENTIALS OFFICE
APO AE
09180
US

V. Phone/Fax

Practice location:
  • Phone: 496371929130
  • Fax: 496371929191
Mailing address:
  • Phone: 496371929130
  • Fax: 496371929191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2462
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: