=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740154004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAFIK DIB, DDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2025
-----------------------------------------------------
Last Update Date | 09/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 JACKS RD
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33897-8007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-888-3374
-----------------------------------------------------
Fax | 863-888-3369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 JACKS RD
-----------------------------------------------------
City | DAVENPORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33897-8007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAFIK DIB
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 863-888-3374
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------