Provider Demographics
NPI:1396025441
Name:INFANTE & GOMEZ PC
Entity Type:Organization
Organization Name:INFANTE & GOMEZ PC
Other - Org Name:GLAD SPECIALIZED FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:P
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:J
Authorized Official - Last Name:INFANTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-645-3286
Mailing Address - Street 1:29 HUDSON RD
Mailing Address - Street 2:3220
Mailing Address - City:SUDBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-1747
Mailing Address - Country:US
Mailing Address - Phone:978-443-4545
Mailing Address - Fax:
Practice Address - Street 1:29 HUDSON RD
Practice Address - Street 2:3220
Practice Address - City:SUDBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-1747
Practice Address - Country:US
Practice Address - Phone:978-443-4545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN215461223P0221X
MADN211171223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1124249826Medicaid
MA1942414263Medicaid