Provider Demographics
NPI:1649378324
Name:DR. RAFAEL GAMBOA
Entity type:Organization
Organization Name:DR. RAFAEL GAMBOA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:775-322-8610
Mailing Address - Street 1:1601 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3408
Mailing Address - Country:US
Mailing Address - Phone:775-322-8610
Mailing Address - Fax:775-322-7698
Practice Address - Street 1:1601 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3408
Practice Address - Country:US
Practice Address - Phone:775-322-8610
Practice Address - Fax:775-322-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty