MEDICARE: LYSETTE M GONZALES PEREZ DMD LLC

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

General Provider Information

NPI Number	:	1588288518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYSETTE M GONZALES PEREZ DMD LLC

Provider Business Mailing Address
First Line	:	19151 S DIXIE HWY STE 206
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33157-7729
Country	:	US
Telephone Number	:	305-256-1303
Fax Number	:

Provider Business Practice Location Address
First Line	:	19151 S DIXIE HWY STE 206
Second Line	:
City	:	CUTLER BAY
State	:	FL
Zip	:	33157-7729
Country	:	US
Telephone Number	:	305-256-1303
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LYSETTE M GONZALEZ PEREZ
Credential	:
Telephone Number	:	787-934-5696

Provider Enumeration Date	:	06/05/2020
Last Update Date	:	06/05/2020

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