Healthcare Provider Details

I. General information

NPI: 1558047241
Provider Name (Legal Business Name): ANDZELIKA GUMIENIAK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515 WESTWORTH BLVD
WESTWORTH VILLAGE TX
76114-4058
US

IV. Provider business mailing address

82 STRONG ST
WALLINGTON NJ
07057-1417
US

V. Phone/Fax

Practice location:
  • Phone: 917-485-1066
  • Fax:
Mailing address:
  • Phone: 917-485-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI3052100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41136
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: