Provider Demographics
NPI:1710153663
Name:PERDOMO, GUSTAVO (DMD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:PERDOMO
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 1:46 ARCADIA RD
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-3202
Mailing Address - Country:US
Mailing Address - Phone:617-966-9159
Mailing Address - Fax:
Practice Address - Street 1:46 ARCADIA RD
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-3202
Practice Address - Country:US
Practice Address - Phone:617-966-9159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216281223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics