Provider Demographics
NPI:1902177843
Name:CLINICA DENTAL LATINA
Entity Type:Organization
Organization Name:CLINICA DENTAL LATINA
Other - Org Name:HANETTE GOMEZ DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ISIDOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-651-7070
Mailing Address - Street 1:9605 40TH RD
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2138
Mailing Address - Country:US
Mailing Address - Phone:718-651-7070
Mailing Address - Fax:718-651-6559
Practice Address - Street 1:9605 40TH RD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2138
Practice Address - Country:US
Practice Address - Phone:718-651-7070
Practice Address - Fax:718-651-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04386311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281218Medicaid