Provider Demographics
NPI:1700057346
Name:RAFAEL VILLACORTA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:RAFAEL VILLACORTA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:VILLACORTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-891-5637
Mailing Address - Street 1:24 CRESCENT ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-4358
Mailing Address - Country:US
Mailing Address - Phone:781-891-5637
Mailing Address - Fax:781-891-8925
Practice Address - Street 1:24 CRESCENT ST
Practice Address - Street 2:SUITE 303
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-4358
Practice Address - Country:US
Practice Address - Phone:781-891-5637
Practice Address - Fax:781-891-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA180631223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0274771Medicaid
MA9708049Medicaid