Provider Demographics
NPI:1043272040
Name:GERARD L. GONSALVES, DMD, PA
Entity Type:Organization
Organization Name:GERARD L. GONSALVES, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONSALVES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-763-1300
Mailing Address - Street 1:2168 MILLBURN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2640
Mailing Address - Country:US
Mailing Address - Phone:973-763-1300
Mailing Address - Fax:973-763-0800
Practice Address - Street 1:2168 MILLBURN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2640
Practice Address - Country:US
Practice Address - Phone:973-763-1300
Practice Address - Fax:973-763-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI016407001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty