Provider Demographics
NPI:1396438784
Name:CANDIDO GOMES DE OLIVEIRA, RUBELISA
Entity type:Individual
Prefix:
First Name:RUBELISA
Middle Name:
Last Name:CANDIDO GOMES DE OLIVEIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 GLENDON PLACE
Mailing Address - Street 2:UNIF F
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:859-536-4891
Mailing Address - Fax:
Practice Address - Street 1:250 SQUIRE HALL RM 250A
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8006
Practice Address - Country:US
Practice Address - Phone:716-829-6294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist