Provider Demographics
NPI:1952778532
Name:SOUZA, SERGIO GOMES DE (DDS)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:GOMES DE
Last Name:SOUZA
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 1:4150 W CHOLLA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3854
Mailing Address - Country:US
Mailing Address - Phone:622-363-8715
Mailing Address - Fax:
Practice Address - Street 1:5115 N DYSART RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-3032
Practice Address - Country:US
Practice Address - Phone:623-536-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-30
Last Update Date:2015-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009301122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist