Provider Demographics
NPI:1659381879
Name:GOMARA, LUIS ANDRES (DMD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANDRES
Last Name:GOMARA
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 1:125 NE 8TH ST
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4676
Mailing Address - Country:US
Mailing Address - Phone:786-243-2438
Mailing Address - Fax:305-247-5744
Practice Address - Street 1:125 NE 8TH ST
Practice Address - Street 2:SUITE # 1
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4676
Practice Address - Country:US
Practice Address - Phone:786-243-2438
Practice Address - Fax:305-247-5744
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0013322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL074957501Medicaid
FL074957502Medicaid
FL074957500Medicaid