Provider Demographics
NPI:1316505530
Name:GOMEZ, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2944
Mailing Address - Country:US
Mailing Address - Phone:914-630-2600
Mailing Address - Fax:
Practice Address - Street 1:22 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2944
Practice Address - Country:US
Practice Address - Phone:917-557-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061191-011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry