Provider Demographics
NPI:1063645455
Name:GONZALEZ, ELMER ELEAZAR (RDH)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:ELEAZAR
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9908 WAGON GATE TRL SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-2611
Mailing Address - Country:US
Mailing Address - Phone:505-280-8214
Mailing Address - Fax:505-272-5299
Practice Address - Street 1:1127 UNIVERSITY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1740
Practice Address - Country:US
Practice Address - Phone:505-272-5326
Practice Address - Fax:505-272-5299
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3025124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist