Healthcare Provider Details

I. General information

NPI: 1881198299
Provider Name (Legal Business Name): TIOGA DENTAL & ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13005 SW 1ST RD STE 233
GAINESVILLE FL
32669-3266
US

IV. Provider business mailing address

13005 SW 1ST RD STE 233
GAINESVILLE FL
32669-3266
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-1946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GOMEZ
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 305-274-2499