Provider Demographics
NPI:1659423101
Name:SIMBACO, RAFAEL DIEGO (DDS PA)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:DIEGO
Last Name:SIMBACO
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 WEST 49TH STREET
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012
Mailing Address - Country:US
Mailing Address - Phone:305-822-9648
Mailing Address - Fax:305-822-9682
Practice Address - Street 1:742 WEST 49TH STREET
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012
Practice Address - Country:US
Practice Address - Phone:305-822-9648
Practice Address - Fax:305-822-9682
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9488122300000X
NY052013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist