1376131052 NPI number — HANETTE GOMEZ DENTISTRY PLLC

Table of content: (NPI 1376131052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376131052 NPI number — HANETTE GOMEZ DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HANETTE GOMEZ DENTISTRY PLLC
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:
Provider Other Organization Name Type Code:
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:
1376131052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9531 156TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOWARD BEACH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11414-2863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-848-7878
Provider Business Mailing Address Fax Number:
718-848-4374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9531 156TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOWARD BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11414-2863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-848-7878
Provider Business Practice Location Address Fax Number:
718-848-4374
Provider Enumeration Date:
01/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
HANETTE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
718-848-7878

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01281218 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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