Healthcare Provider Details

I. General information

NPI: 1720535545
Provider Name (Legal Business Name): ENIO GOMEZ RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 COLUMBUS AVE
NEW HAVEN CT
06519-1233
US

IV. Provider business mailing address

400 COLUMBUS AVE
NEW HAVEN CT
06519-1233
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3040
  • Fax: 203-503-3187
Mailing address:
  • Phone: 203-503-3174
  • Fax: 203-503-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7865
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: