Provider Demographics
NPI:1184202814
Name:LUIS F GOMEZ DDS PA
Entity Type:Organization
Organization Name:LUIS F GOMEZ DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-649-1054
Mailing Address - Street 1:4651 N STATE ROAD 7 STE 4
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4378
Mailing Address - Country:US
Mailing Address - Phone:954-510-4300
Mailing Address - Fax:
Practice Address - Street 1:4651 N STATE ROAD 7 STE 4
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4378
Practice Address - Country:US
Practice Address - Phone:954-510-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUIS F GOMEZ DDS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1689899452Medicaid