Healthcare Provider Details

I. General information

NPI: 1821832270
Provider Name (Legal Business Name): JONATHAN GOMOGDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11345 US HIGHWAY 301 S STE 104
RIVERVIEW FL
33578-6279
US

IV. Provider business mailing address

11345 US HIGHWAY 301 S STE 104
RIVERVIEW FL
33578-6279
US

V. Phone/Fax

Practice location:
  • Phone: 813-367-9496
  • Fax:
Mailing address:
  • Phone: 813-367-9496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN31712
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: