Provider Demographics
NPI:1538792635
Name:PIEDRA, GUSTAVO (DDS)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:PIEDRA
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 1:4578 SW 174TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5618
Mailing Address - Country:US
Mailing Address - Phone:786-486-5553
Mailing Address - Fax:
Practice Address - Street 1:9777 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-4615
Practice Address - Country:US
Practice Address - Phone:305-596-2815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26816122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist