Provider Demographics
NPI:1952471708
Name:VILLACORTA, RAFAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:VILLACORTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CRESCENT ST
Mailing Address - Street 2:STE 303
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453
Mailing Address - Country:US
Mailing Address - Phone:781-891-5637
Mailing Address - Fax:781-891-8926
Practice Address - Street 1:24 CRESCENT ST
Practice Address - Street 2:STE 303
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453
Practice Address - Country:US
Practice Address - Phone:781-891-5637
Practice Address - Fax:781-891-8926
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA180631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9708049Medicaid
MA0274771Medicaid