Provider Demographics
NPI:1114330586
Name:FONSECA, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:LUIS
Other - Middle Name:M
Other - Last Name:FONSECA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4690 SAINT CROIX LN APT 418
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3559
Mailing Address - Country:US
Mailing Address - Phone:239-316-9044
Mailing Address - Fax:
Practice Address - Street 1:28441 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-3212
Practice Address - Country:US
Practice Address - Phone:239-316-9044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN222731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice