Healthcare Provider Details

I. General information

NPI: 1497329551
Provider Name (Legal Business Name): EDGAR ROMAN GOMEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDGAR ROMAN GOMEZ HERNANDEZ DDS

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date: 11/07/2023
Reactivation Date: 12/22/2023

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-1450
US

IV. Provider business mailing address

1959 NE PACIFIC ST
SEATTLE WA
98195-6365
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-0903
  • Fax:
Mailing address:
  • Phone: 206-543-0903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.70131492
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDENT.DE.70131492
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: