Provider Demographics
NPI:1811037542
Name:GOMEZ, MICHAEL RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-0908
Mailing Address - Country:US
Mailing Address - Phone:323-581-3226
Mailing Address - Fax:323-585-0203
Practice Address - Street 1:2639 WALNUT ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5709
Practice Address - Country:US
Practice Address - Phone:323-581-3226
Practice Address - Fax:323-585-0203
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31919 D.D.S.1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice