Provider Demographics
NPI:1376633479
Name:MERCADO, RAFAEL L (DDS)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:L
Last Name:MERCADO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 NW MILITARY HWY
Mailing Address - Street 2:SUITE 225
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2153
Mailing Address - Country:US
Mailing Address - Phone:210-732-4570
Mailing Address - Fax:
Practice Address - Street 1:1931 NW MILITARY HWY
Practice Address - Street 2:SUITE 225
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2153
Practice Address - Country:US
Practice Address - Phone:210-732-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306173554OtherTYPE 2 BUSINESS NPI
TX180123502Medicaid
TX1376774851OtherNPI
TX136341809Medicaid