Provider Demographics
NPI:1184925653
Name:GATEWAY DENTAL
Entity type:Organization
Organization Name:GATEWAY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-856-2300
Mailing Address - Street 1:2375 SW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3641
Mailing Address - Country:US
Mailing Address - Phone:305-856-2300
Mailing Address - Fax:305-856-0921
Practice Address - Street 1:2375 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-3641
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:2010-11-15
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101340700Medicaid