Provider Demographics
NPI:1073575130
Name:GONZALEZ, JUAN FERNANDO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:FERNANDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 SANDY BROOK DR STE 204
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1518
Mailing Address - Country:US
Mailing Address - Phone:512-375-0050
Mailing Address - Fax:512-682-9009
Practice Address - Street 1:4010 SANDY BROOK DR STE 204
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1518
Practice Address - Country:US
Practice Address - Phone:512-375-0050
Practice Address - Fax:512-682-9009
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218656102Medicaid
TX22953OtherLICENSE