Provider Demographics
NPI:1649301102
Name:GOMEZ, KRISTINE L (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:L
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-2241
Mailing Address - Country:US
Mailing Address - Phone:520-364-9718
Mailing Address - Fax:520-805-9391
Practice Address - Street 1:720 E 11TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2241
Practice Address - Country:US
Practice Address - Phone:520-364-9718
Practice Address - Fax:520-805-9391
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist