Provider Demographics
NPI:1669504403
Name:URDANETA, RAINIER A (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAINIER
Middle Name:A
Last Name:URDANETA
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 1:25 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02466-2103
Mailing Address - Country:US
Mailing Address - Phone:617-527-8554
Mailing Address - Fax:
Practice Address - Street 1:501 ARBORWAY
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3663
Practice Address - Country:US
Practice Address - Phone:617-524-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist