=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922462506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS GABRIEL NATAL DELIZ DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2016
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR. #3 KM. 32.9 BO. TRES T INSTITUTO CORRECCIONAL ZARZAL
-----------------------------------------------------
City | RIO GRANDE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-236-8728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4166 GAUGE LINE LOOP
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33624-5130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-236-8728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN23435
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------