Provider Demographics
NPI:1881567634
Name:IMG DENTAL, PLLC
Entity type:Organization
Organization Name:IMG DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:IVETH
Authorized Official - Middle Name:MAGALY
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-762-0381
Mailing Address - Street 1:780 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-4991
Mailing Address - Country:US
Mailing Address - Phone:321-631-5600
Mailing Address - Fax:
Practice Address - Street 1:780 WEST AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-4991
Practice Address - Country:US
Practice Address - Phone:321-631-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty