Healthcare Provider Details

I. General information

NPI: 1114034600
Provider Name (Legal Business Name): JEFF CHARLES RAPHAEL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

IV. Provider business mailing address

99 FURNACE ST
SHARON MA
02067-2845
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-5124
  • Fax: 857-364-2040
Mailing address:
  • Phone: 781-784-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number5675
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: