Provider Demographics
NPI:1538830344
Name:GERVASIO-FLORES, LUIS FERNANDO (DMD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:GERVASIO-FLORES
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 1:5 CABOT RD UNIT 117
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5280
Mailing Address - Country:US
Mailing Address - Phone:305-713-7431
Mailing Address - Fax:
Practice Address - Street 1:331 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-1905
Practice Address - Country:US
Practice Address - Phone:781-300-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18591821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice