Healthcare Provider Details

I. General information

NPI: 1427442177
Provider Name (Legal Business Name): RAQUEL MARIE FONTANEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 GRAND CONCOURSE FL 6
BRONX NY
10453-8202
US

IV. Provider business mailing address

1800 N FIELD ST APT 1603
DALLAS TX
75202-2764
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8110
  • Fax:
Mailing address:
  • Phone: 787-710-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number25734
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: