Provider Demographics
NPI:1962709295
Name:GENO, JOSE RAFAEL (DMD, PA)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAFAEL
Last Name:GENO
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 SW 16TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2067
Mailing Address - Country:US
Mailing Address - Phone:305-854-8707
Mailing Address - Fax:305-854-8720
Practice Address - Street 1:2200 SW 16TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2067
Practice Address - Country:US
Practice Address - Phone:305-854-8707
Practice Address - Fax:305-854-8720
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN104991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071957900Medicaid