Basic Information
| Provider Information | |||||||||
| NPI: | 1063030393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RASCON | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | GONZALEZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 S ALAMEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880052818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755286470 | ||||||||
| FaxNumber: | 5755562930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD5289 | NM | Y | Dental Providers | Dentist | General Practice |
No ID Information.