Provider Demographics
NPI:1477044303
Name:CHAVEZ, RAFAEL (DDS)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CHAVEZ
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 1:3502 ANGELUCCI ST APT 109
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SANTIAGO ARGUELLO #736
Practice Address - Street 2:PLAZA SANTA CECILIA
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:619-808-1791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-26
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1951743122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist