Provider Demographics
NPI:1306254156
Name:PARDO, GUSTAVO (DDS)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:PARDO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-226-4650
Practice Address - Street 1:930 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-4448
Practice Address - Country:US
Practice Address - Phone:863-675-0387
Practice Address - Fax:863-675-3246
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20829122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012768900Medicaid