Provider Demographics
NPI:1669761250
Name:ROMO DE MIGUEL, GONZALO (DDS)
Entity type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:ROMO DE MIGUEL
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 1:5 WEBSTER SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2326
Mailing Address - Country:US
Mailing Address - Phone:347-237-2824
Mailing Address - Fax:
Practice Address - Street 1:5 WEBSTER SQUARE RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2326
Practice Address - Country:US
Practice Address - Phone:860-828-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0109011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice