Healthcare Provider Details

I. General information

NPI: 1154726131
Provider Name (Legal Business Name): RAFAEL A. GAVILANES - MENDEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 AVE GENERAL RAMEY STE 1
SAN ANTONIO PR
00690
US

IV. Provider business mailing address

PO BOX 784
SAN ANTONIO PR
00690-0784
US

V. Phone/Fax

Practice location:
  • Phone: 787-510-0912
  • Fax:
Mailing address:
  • Phone: 787-510-0912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3250
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: