Healthcare Provider Details

I. General information

NPI: 1588288518
Provider Name (Legal Business Name): LYSETTE M GONZALES PEREZ DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19151 S DIXIE HWY STE 206
CUTLER BAY FL
33157-7729
US

IV. Provider business mailing address

19151 S DIXIE HWY STE 206
CUTLER BAY FL
33157-7729
US

V. Phone/Fax

Practice location:
  • Phone: 305-256-1303
  • Fax:
Mailing address:
  • Phone: 305-256-1303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LYSETTE M GONZALEZ PEREZ
Title or Position: OWNER
Credential:
Phone: 787-934-5696