Provider Demographics
NPI:1538312525
Name:BRAVO, RAQUEL A (DMD)
Entity Type:Individual
Prefix:MISS
First Name:RAQUEL
Middle Name:A
Last Name:BRAVO
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 1:8977 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1925
Mailing Address - Country:US
Mailing Address - Phone:786-507-1551
Mailing Address - Fax:305-251-9766
Practice Address - Street 1:8977 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1925
Practice Address - Country:US
Practice Address - Phone:786-507-1551
Practice Address - Fax:305-251-9766
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17123122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist