Provider Demographics
NPI:1649231077
Name:BARANOV, RAQUEL ITA (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:ITA
Last Name:BARANOV
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6123
Mailing Address - Country:US
Mailing Address - Phone:928-819-8999
Mailing Address - Fax:928-539-5579
Practice Address - Street 1:2060 W 24TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6123
Practice Address - Country:US
Practice Address - Phone:928-819-8999
Practice Address - Fax:928-539-5579
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD57621223G0001X
ORD81231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ735102Medicaid