Provider Demographics
NPI:1093855264
Name:SUSTENTO, RAFAEL POBLETE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:POBLETE
Last Name:SUSTENTO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23206 LYONS AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2672
Mailing Address - Country:US
Mailing Address - Phone:661-799-9828
Mailing Address - Fax:661-799-2823
Practice Address - Street 1:23206 LYONS AVE STE 208
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2672
Practice Address - Country:US
Practice Address - Phone:661-799-9828
Practice Address - Fax:661-799-9823
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice