MEDICARE: LYSETTE M GONZALEZ PEREZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN23271	FL

General Provider Information

NPI Number	:	1083153357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYSETTE M GONZALEZ PEREZ

Provider Business Mailing Address
First Line	:	92 SW 3RD ST APT 4512
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33130-3385
Country	:	US
Telephone Number	:	787-934-5696
Fax Number	:

Provider Business Practice Location Address
First Line	:	92 SW 3RD ST APT 4512
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33130-3385
Country	:	US
Telephone Number	:	787-934-5696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2017
Last Update Date	:	06/05/2020

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