Provider Demographics
NPI:1306902325
Name:GUMUCIO, NELSON MARTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:MARTIN
Last Name:GUMUCIO
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 1:13005 SOUTHERN BLVD
Mailing Address - Street 2:SUITE # 143
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9206
Mailing Address - Country:US
Mailing Address - Phone:561-790-5414
Mailing Address - Fax:561-790-1052
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:SUITE # 143
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-790-5414
Practice Address - Fax:561-790-1052
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN92211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice