Provider Demographics
NPI:1013405992
Name:GONZALEZ JAIMES, EDITH SOCORRO (DDS)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:SOCORRO
Last Name:GONZALEZ JAIMES
Suffix:
Gender:F
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:PO BOX 4947
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058
Mailing Address - Country:US
Mailing Address - Phone:540-223-5602
Mailing Address - Fax:
Practice Address - Street 1:121 PARK HILL DR.
Practice Address - Street 2:SUITE A
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-373-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0401417411122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program