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General NPI Number Information
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NPI Number | 1700057346
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Entity Type | Organization
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Legal Business Name | RAFAEL VILLACORTA FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/21/2008
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Last Update Date | 03/21/2008
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Provider Practice Location Address
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Address Line | 24 CRESCENT ST SUITE 303
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City | WALTHAM
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State | MA
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Zip | 02453-4358
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Country | US
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Telephone | 781-891-5637
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Fax | 781-891-8925
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Provider Business Mailing Address
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Address Line | 24 CRESCENT ST SUITE 303
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City | WALTHAM
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State | MA
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Zip | 02453-4358
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Country | US
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Telephone | 781-891-5637
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Fax | 781-891-8925
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RAFAEL E VILLACORTA
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Credential | DMD
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Telephone | 781-891-5637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number | 18063
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License Number State | MA
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