Healthcare Provider Details

I. General information

NPI: 1225980709
Provider Name (Legal Business Name): JUAN J MARIN GAVIRIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 POINTE LOOP DR
VENICE FL
34293-5261
US

IV. Provider business mailing address

528 VISTERA BLVD UNIT 5003
NORTH VENICE FL
34275-4049
US

V. Phone/Fax

Practice location:
  • Phone: 941-401-9621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN32533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: