Provider Demographics
NPI:1528027844
Name:LABODA, GERALD (DMD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:LABODA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5285 SUMMERLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-7602
Mailing Address - Country:US
Mailing Address - Phone:239-938-3020
Mailing Address - Fax:239-936-1139
Practice Address - Street 1:5285 SUMMERLIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7602
Practice Address - Country:US
Practice Address - Phone:239-938-3020
Practice Address - Fax:239-936-1139
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40442Medicare ID - Type UnspecifiedGROUP NUMBER
FL83613ZMedicare ID - Type Unspecified
FLT55131Medicare UPIN