Provider Demographics
NPI:1497764286
Name:CARABALLO, RAFAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:CARABALLO
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:CMR 402
Mailing Address - Street 2:LANDSTUHL DENTAL ACTIVITY, CREDENTIALS OFFICE
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:49637-192-9130
Mailing Address - Fax:49637-192-9191
Practice Address - Street 1:CMR 402
Practice Address - Street 2:LANDSTUHL DENTAL ACTIVITY, CREDENTIALS OFFICE
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:49637-192-9130
Practice Address - Fax:49637-192-9191
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2462122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist