Healthcare Provider Details

I. General information

NPI: 1588198667
Provider Name (Legal Business Name): RAFAEL CARMONA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 TREMONT ST FL 2
ROXBURY MA
02120-3432
US

IV. Provider business mailing address

1290 TREMONT ST FL 2
ROXBURY MA
02120-3432
US

V. Phone/Fax

Practice location:
  • Phone: 617-989-3229
  • Fax: 617-858-2664
Mailing address:
  • Phone: 617-989-3229
  • Fax: 617-858-2664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDL13223
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: