Provider Demographics
NPI:1093188856
Name:GONZALEZ DENTAL LAB
Entity Type:Organization
Organization Name:GONZALEZ DENTAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:P
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-975-1292
Mailing Address - Street 1:1065 NW 129TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-2324
Mailing Address - Country:US
Mailing Address - Phone:305-975-1292
Mailing Address - Fax:
Practice Address - Street 1:921 SW 122ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2477
Practice Address - Country:US
Practice Address - Phone:305-975-1292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDL 11401292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory