Provider Demographics
NPI:1063141711
Name:PADILLA MIRABAL, RAISA
Entity type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:PADILLA MIRABAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 GULF LN
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-4759
Mailing Address - Country:US
Mailing Address - Phone:786-344-0427
Mailing Address - Fax:
Practice Address - Street 1:2232 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3717
Practice Address - Country:US
Practice Address - Phone:239-344-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29534122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist