MEDICARE: GOMEZ & REVUELTA,DDS,PA

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	1223G0001X	General Practice Dentistry	DN12049	FL

General Provider Information

NPI Number	:	1912195033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOMEZ & REVUELTA,DDS,PA

Provider Business Mailing Address
First Line	:	1255 W 46TH ST STE 1
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-3257
Country	:	US
Telephone Number	:	305-558-2933
Fax Number	:	305-558-6970

Provider Business Practice Location Address
First Line	:	1255 W 46TH ST STE 1
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-3257
Country	:	US
Telephone Number	:	305-558-2933
Fax Number	:	305-558-6970

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. ANA MARIA REVUELTA
Credential	:
Telephone Number	:	305-558-2933

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	10/15/2007

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