Healthcare Provider Details

I. General information

NPI: 1306902325
Provider Name (Legal Business Name): NELSON MARTIN GUMUCIO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13005 SOUTHERN BLVD SUITE # 143
LOXAHATCHEE FL
33470-9206
US

IV. Provider business mailing address

13005 SOUTHERN BLVD SUITE # 143
LOXAHATCHEE FL
33470-9206
US

V. Phone/Fax

Practice location:
  • Phone: 561-790-5414
  • Fax: 561-790-1052
Mailing address:
  • Phone: 561-790-5414
  • Fax: 561-790-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN9221
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: