Healthcare Provider Details

I. General information

NPI: 1497887863
Provider Name (Legal Business Name): DENISE GOMARA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 COUNTY ROAD 17A W
AVON PARK FL
33825-2164
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 863-452-3000
  • Fax: 863-452-3002
Mailing address:
  • Phone: 863-291-5110
  • Fax: 863-291-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN16346
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: