Healthcare Provider Details

I. General information

NPI: 1902142722
Provider Name (Legal Business Name): RAFIK DIB DDS, MSD, PHARMD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 JACKS RD
DAVENPORT FL
33897-8007
US

IV. Provider business mailing address

2600 JACKS RD
DAVENPORT FL
33897-8007
US

V. Phone/Fax

Practice location:
  • Phone: 863-888-3374
  • Fax:
Mailing address:
  • Phone: 863-888-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19121
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN22644
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6475
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: