Provider Demographics
NPI:1497887863
Name:GOMARA, DENISE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:
Last Name:GOMARA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:863-291-5110
Mailing Address - Fax:863-291-5128
Practice Address - Street 1:950 COUNTY ROAD 17A W
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2164
Practice Address - Country:US
Practice Address - Phone:863-452-3000
Practice Address - Fax:863-452-3002
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN163461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009784700Medicaid