Provider Demographics
NPI:1750098539
Name:LUGO-GONZALEZ, VIVIENNE M (DMD)
Entity type:Individual
Prefix:
First Name:VIVIENNE
Middle Name:M
Last Name:LUGO-GONZALEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 KNOLLPOINT DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8843
Mailing Address - Country:US
Mailing Address - Phone:939-640-7094
Mailing Address - Fax:
Practice Address - Street 1:4144 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6400
Practice Address - Country:US
Practice Address - Phone:786-317-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL275731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice