Provider Demographics
NPI:1861834905
Name:GATEWAY DENTAL
Entity Type:Organization
Organization Name:GATEWAY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-325-0050
Mailing Address - Street 1:1050 NW 14TH ST # 204
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2105
Mailing Address - Country:US
Mailing Address - Phone:305-856-2300
Mailing Address - Fax:305-856-0921
Practice Address - Street 1:1050 NW 14TH ST # 204
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2105
Practice Address - Country:US
Practice Address - Phone:305-856-2300
Practice Address - Fax:305-856-0921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101365200Medicaid