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General NPI Number Information
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NPI Number | 1649378324
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Entity Type | Organization
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Legal Business Name | DR. RAFAEL GAMBOA
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1601 LAKESIDE DR
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City | RENO
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State | NV
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Zip | 89509-3408
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Country | US
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Telephone | 775-322-8610
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Fax | 775-322-7698
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Provider Business Mailing Address
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Address Line | 1601 LAKESIDE DR
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City | RENO
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State | NV
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Zip | 89509-3408
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Country | US
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Telephone | 775-322-8610
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Fax | 775-322-7698
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RAFAEL M GAMBOA
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Credential | DDS
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Telephone | 775-322-8610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 913
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License Number State | NV
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