Provider Demographics
NPI:1043530736
Name:THOMAS R GONZALES, D.D.S.
Entity Type:Organization
Organization Name:THOMAS R GONZALES, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-798-6684
Mailing Address - Street 1:11506 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90601-3105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11506 BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90601-3105
Practice Address - Country:US
Practice Address - Phone:562-695-8718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2427332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment