Provider Demographics
NPI:1073962965
Name:BLANCO, RAQUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 NW 43RD ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-3332
Mailing Address - Country:US
Mailing Address - Phone:352-378-3139
Mailing Address - Fax:352-371-0135
Practice Address - Street 1:5622 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-3332
Practice Address - Country:US
Practice Address - Phone:352-378-3139
Practice Address - Fax:352-371-0135
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21880122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist