Healthcare Provider Details

I. General information

NPI: 1043635071
Provider Name (Legal Business Name): TASHORN GOMEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 GRAND CONCOURSE 6TH FLOOR
BRONX NY
10453-8202
US

IV. Provider business mailing address

1775 GRAND CONCOURSE 6TH FLOOR
BRONX NY
10453-8202
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-8110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number057213
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: