Provider Demographics
NPI:1083153357
Name:GONZALEZ PEREZ, LYSETTE M
Entity Type:Individual
Prefix:
First Name:LYSETTE
Middle Name:M
Last Name:GONZALEZ PEREZ
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 1:92 SW 3RD ST APT 4512
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3385
Mailing Address - Country:US
Mailing Address - Phone:787-934-5696
Mailing Address - Fax:
Practice Address - Street 1:92 SW 3RD ST APT 4512
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3385
Practice Address - Country:US
Practice Address - Phone:787-934-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-19
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23271122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program