Provider Demographics
NPI:1598121402
Name:MONDRAGON VELEZ, GLORIA C (DMD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:C
Last Name:MONDRAGON VELEZ
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 1:510 NW 84 AVE APT 539
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2120
Mailing Address - Country:US
Mailing Address - Phone:786-515-5772
Mailing Address - Fax:
Practice Address - Street 1:2730 UNIVERSITY BLVD W STE 1010
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5902
Practice Address - Country:US
Practice Address - Phone:240-752-8822
Practice Address - Fax:240-752-8821
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21573122300000X, 1223P0221X
MD171731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN21573OtherFLORIDA DEPARTMENT OF HEALTH MQA