Provider Demographics
NPI:1326163114
Name:GOMEZ, SANDRA P (DDS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:P
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 1:2829 N.E 33RD COURT #405
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306
Mailing Address - Country:US
Mailing Address - Phone:954-564-5725
Mailing Address - Fax:
Practice Address - Street 1:1740 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-958-3584
Practice Address - Fax:954-958-3585
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 165041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-5495196OtherTIN