Provider Demographics
NPI:1427551878
Name:BRAVO GONZALEZ, ERNESTO LEANDRO
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:LEANDRO
Last Name:BRAVO GONZALEZ
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 1:5710 ATLANTA ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2717
Mailing Address - Country:US
Mailing Address - Phone:781-990-6564
Mailing Address - Fax:
Practice Address - Street 1:4700 SHERIDAN ST STE A1
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3416
Practice Address - Country:US
Practice Address - Phone:954-966-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25161122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist