Provider Demographics
NPI:1912195033
Name:GOMEZ & REVUELTA,DDS,PA
Entity Type:Organization
Organization Name:GOMEZ & REVUELTA,DDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:REVUELTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-558-2933
Mailing Address - Street 1:1255 W 46TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3257
Mailing Address - Country:US
Mailing Address - Phone:305-558-2933
Mailing Address - Fax:305-558-6970
Practice Address - Street 1:1255 W 46TH ST STE 1
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3257
Practice Address - Country:US
Practice Address - Phone:305-558-2933
Practice Address - Fax:305-558-6970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN120491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty