Provider Demographics
NPI:1669979639
Name:RDC DENTAL PA
Entity type:Organization
Organization Name:RDC DENTAL PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CEPEDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-717-9161
Mailing Address - Street 1:305 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-2748
Mailing Address - Country:US
Mailing Address - Phone:904-717-9161
Mailing Address - Fax:904-717-9167
Practice Address - Street 1:305 E UNION ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-2748
Practice Address - Country:US
Practice Address - Phone:904-717-9161
Practice Address - Fax:904-717-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17040261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003095300Medicaid