Provider Demographics
NPI:1083067870
Name:GONZALEZ GUSMAO, ILENIA ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:ILENIA
Middle Name:ELIZABETH
Last Name:GONZALEZ GUSMAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 W SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1322
Mailing Address - Country:US
Mailing Address - Phone:202-802-7337
Mailing Address - Fax:
Practice Address - Street 1:20 CENTRAL ST STE 111
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3752
Practice Address - Country:US
Practice Address - Phone:617-636-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18597941223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics