Provider Demographics
NPI:1134935026
Name:GOMEZ MUNOZ, IVAN (DDS)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:GOMEZ MUNOZ
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 1:12900 FILMORE ST UNIT 103
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5807 N FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4227
Practice Address - Country:US
Practice Address - Phone:323-982-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist