Provider Demographics
NPI:1124629373
Name:RONDON, RAFAEL R (RDH)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:R
Last Name:RONDON
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 BEARGRASS RD
Mailing Address - Street 2:
Mailing Address - City:HARMONY
Mailing Address - State:FL
Mailing Address - Zip Code:34773-9182
Mailing Address - Country:US
Mailing Address - Phone:407-819-9057
Mailing Address - Fax:
Practice Address - Street 1:5706 BENJAMIN CENTER DR STE 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5262
Practice Address - Country:US
Practice Address - Phone:813-288-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH16473124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist