=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659589679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS GOMEZ DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 12/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3915 W LINCOLN HWY
-----------------------------------------------------
City | DOWNINGTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19335-5502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-269-1900
-----------------------------------------------------
Fax | 610-269-2725
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 LIZBETH LN
-----------------------------------------------------
City | BERWYN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19312-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-678-5108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DS035791
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------