Provider Demographics
NPI:1588198667
Name:CARMONA, RAFAEL (DMD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CARMONA
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 1:1290 TREMONT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3432
Mailing Address - Country:US
Mailing Address - Phone:617-989-3229
Mailing Address - Fax:617-858-2664
Practice Address - Street 1:1290 TREMONT ST FL 2
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02120-3432
Practice Address - Country:US
Practice Address - Phone:617-989-3229
Practice Address - Fax:617-858-2664
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL132231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics