Provider Demographics
NPI:1417699570
Name:GOMEZ PLA, CAMILO ANDRES
Entity Type:Individual
Prefix:
First Name:CAMILO
Middle Name:ANDRES
Last Name:GOMEZ PLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970-0426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 CALLE CARAZO
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-5715
Practice Address - Country:US
Practice Address - Phone:787-731-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-10
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR34711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice