Healthcare Provider Details

I. General information

NPI: 1659423101
Provider Name (Legal Business Name): RAFAEL DIEGO SIMBACO DDS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 WEST 49TH STREET
HIALEAH FL
33012
US

IV. Provider business mailing address

742 WEST 49TH STREET
HIALEAH FL
33012
US

V. Phone/Fax

Practice location:
  • Phone: 305-822-9648
  • Fax: 305-822-9682
Mailing address:
  • Phone: 305-822-9648
  • Fax: 305-822-9682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN9488
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number052013
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: