Basic Information
Provider Information | |||||||||
NPI: | 1275055535 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOMES | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | SHAGOR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 21145 SPRING PLAZA DR APT 4108 | ||||||||
Address2: |   | ||||||||
City: | SPRING | ||||||||
State: | TX | ||||||||
PostalCode: | 773881447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144053635 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 RESEARCH FOREST DR STE 220 | ||||||||
Address2: |   | ||||||||
City: | SHENANDOAH | ||||||||
State: | TX | ||||||||
PostalCode: | 773817300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2818594624 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2017 | ||||||||
LastUpdateDate: | 07/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 32993 | TX | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.