Provider Demographics
NPI:1982621538
Name:GOMEZ, MARTHA VIVIANA (DDS)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:VIVIANA
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 1:100 MINGES CREEK PL APT E302
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-4292
Mailing Address - Country:US
Mailing Address - Phone:734-277-7012
Mailing Address - Fax:517-639-5761
Practice Address - Street 1:8 N MAIN ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MI
Practice Address - Zip Code:49082-1186
Practice Address - Country:US
Practice Address - Phone:517-639-7151
Practice Address - Fax:517-639-5761
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010188091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice