Provider Demographics
NPI:1265091185
Name:GOMEZ, DALLIN (DDS)
Entity type:Individual
Prefix:
First Name:DALLIN
Middle Name:
Last Name:GOMEZ
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 1:7496 FOOTHILL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE POINT
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8925
Mailing Address - Country:US
Mailing Address - Phone:801-472-3105
Mailing Address - Fax:
Practice Address - Street 1:2200 GRANDE BLVD SE STE A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1695
Practice Address - Country:US
Practice Address - Phone:505-891-1500
Practice Address - Fax:972-590-8809
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11297718-99221223G0001X
NMDD51161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice