Provider Demographics
NPI:1487006649
Name:GOMEZ MARROQUIN, ERICK FERNANDO
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:FERNANDO
Last Name:GOMEZ MARROQUIN
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 1:34 CAMBRIDGE STREET
Mailing Address - Street 2:APARTMENT 2211
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129
Mailing Address - Country:US
Mailing Address - Phone:860-515-9228
Mailing Address - Fax:
Practice Address - Street 1:ONE KNEELAND ST
Practice Address - Street 2:ROOM 416
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-6814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2022-10-28
Deactivation Date:2021-10-22
Deactivation Code:
Reactivation Date:2021-11-15
Provider Licenses
StateLicense IDTaxonomies
MADF11773122300000X
FLDN238541223X2210X
MADF11888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X2210XDental ProvidersDentistOrofacial Pain