1396025441 NPI number — INFANTE & GOMEZ PC

Table of content: (NPI 1396025441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396025441 NPI number — INFANTE & GOMEZ PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFANTE & GOMEZ PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GLAD SPECIALIZED FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396025441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 HUDSON RD
Provider Second Line Business Mailing Address:
3220
Provider Business Mailing Address City Name:
SUDBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01776-1747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-443-4545
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 HUDSON RD
Provider Second Line Business Practice Location Address:
3220
Provider Business Practice Location Address City Name:
SUDBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01776-1747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-443-4545
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
INFANTE
Authorized Official First Name:
GUSTAVO
Authorized Official Middle Name:
J
Authorized Official Title or Position:
P
Authorized Official Telephone Number:
617-645-3286

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DN21546 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0700X , with the licence number: DN21117 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1124249826 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1942414263 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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