Healthcare Provider Details

I. General information

NPI: 1952927295
Provider Name (Legal Business Name): RAFAEL LLANES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5516 S STATE ROAD 7 STE 132
LAKE WORTH FL
33449-5442
US

IV. Provider business mailing address

5516 S STATE ROAD 7 STE 132
LAKE WORTH FL
33449-5442
US

V. Phone/Fax

Practice location:
  • Phone: 561-963-7950
  • Fax:
Mailing address:
  • Phone: 561-963-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN25022
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: