Provider Demographics
NPI:1396102190
Name:POU, RAFAEL TEOVALDO
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:TEOVALDO
Last Name:POU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 W LA HABRA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-5307
Mailing Address - Country:US
Mailing Address - Phone:714-550-7172
Mailing Address - Fax:
Practice Address - Street 1:545 W LA HABRA BLVD
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-5307
Practice Address - Country:US
Practice Address - Phone:714-550-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100004122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist