MEDICARE: DR. CARLOS GOMEZ DMD

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	1223P0221X	Pediatric Dentistry	DS035791	PA

General Provider Information

NPI Number	:	1659589679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS GOMEZ DMD

Provider Business Mailing Address
First Line	:	22 LIZBETH LN
Second Line	:
City	:	BERWYN
State	:	PA
Zip	:	19312-1210
Country	:	US
Telephone Number	:	484-678-5108
Fax Number	:

Provider Business Practice Location Address
First Line	:	3915 W LINCOLN HWY
Second Line	:
City	:	DOWNINGTOWN
State	:	PA
Zip	:	19335-5502
Country	:	US
Telephone Number	:	610-269-1900
Fax Number	:	610-269-2725

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	12/19/2012

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