Provider Demographics
NPI:1992366520
Name:GAMBOA, LUIS FERNANDO (DMD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:GAMBOA
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 1:7885 NW 107 AVE
Mailing Address - Street 2:BUILDING 5, SUITE 4
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4427
Mailing Address - Country:US
Mailing Address - Phone:305-307-7017
Mailing Address - Fax:
Practice Address - Street 1:7885 NW 107 AVE
Practice Address - Street 2:BUILDING 5, SUITE 4
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4427
Practice Address - Country:US
Practice Address - Phone:305-307-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24349122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist