Healthcare Provider Details

I. General information

NPI: 1144203878
Provider Name (Legal Business Name): JORGE LUIS GOMEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8397 WOODHAVEN BLVD
WOODHAVEN NY
11421-1531
US

IV. Provider business mailing address

8397 WOODHAVEN BLVD
WOODHAVEN NY
11421-1531
US

V. Phone/Fax

Practice location:
  • Phone: 718-805-0450
  • Fax:
Mailing address:
  • Phone: 718-805-0450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number040435
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: