Provider Demographics
NPI:1124505268
Name:CORTES FONTANET, RAISA
Entity type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:CORTES FONTANET
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 1:850 SW 2ND AVE UNIT 1002
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3594
Mailing Address - Country:US
Mailing Address - Phone:786-715-5571
Mailing Address - Fax:
Practice Address - Street 1:747 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2049
Practice Address - Country:US
Practice Address - Phone:305-444-8591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN243621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program