Provider Demographics
NPI:1043635071
Name:GOMEZ, TASHORN (DDS)
Entity Type:Individual
Prefix:
First Name:TASHORN
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 GRAND CONCOURSE
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-8202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1775 GRAND CONCOURSE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-8202
Practice Address - Country:US
Practice Address - Phone:718-901-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0572131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery