Provider Demographics
NPI:1992366520
Name:GAMBOA, LUIS FERNANDO (DMD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 NEW BERN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1200
Mailing Address - Country:US
Mailing Address - Phone:984-242-0568
Mailing Address - Fax:
Practice Address - Street 1:3110 NEW BERN AVE STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1200
Practice Address - Country:US
Practice Address - Phone:984-242-0568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC117011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice