Provider Demographics
NPI:1497184097
Name:BALBOA, RAFAEL G (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:G
Last Name:BALBOA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14527 SW 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175
Mailing Address - Country:US
Mailing Address - Phone:786-488-2895
Mailing Address - Fax:305-328-9636
Practice Address - Street 1:14527 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-7801
Practice Address - Country:US
Practice Address - Phone:786-488-2895
Practice Address - Fax:305-328-9636
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist