Healthcare Provider Details

I. General information

NPI: 1184224230
Provider Name (Legal Business Name): GUSTAVO HERNAN LOPEZ GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BROADWAY RM 1304
NEW YORK NY
10006-1999
US

IV. Provider business mailing address

39 HIGH ST APT 309
JERSEY CITY NJ
07306-2360
US

V. Phone/Fax

Practice location:
  • Phone: 212-600-1996
  • Fax:
Mailing address:
  • Phone: 813-447-0053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number062406-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: