Healthcare Provider Details

I. General information

NPI: 1841742319
Provider Name (Legal Business Name): RAPHAEL LIY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 HEALTH CARE DR BLDG 6
TRINITY FL
34655-5362
US

IV. Provider business mailing address

1822 HEALTH CARE DR BLDG 6
TRINITY FL
34655-5362
US

V. Phone/Fax

Practice location:
  • Phone: 727-848-5525
  • Fax:
Mailing address:
  • Phone: 727-848-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberLL-435-16
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN24283
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: