Provider Demographics
NPI:1942663547
Name:VIDAL, GABRIEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:A
Last Name:VIDAL
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 1:8020 SW 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-8230
Mailing Address - Country:US
Mailing Address - Phone:786-223-3935
Mailing Address - Fax:
Practice Address - Street 1:401 SW 42ND AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1938
Practice Address - Country:US
Practice Address - Phone:305-445-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14960122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist