Provider Demographics
NPI:1093461543
Name:REYNAGA GONZALEZ, GERARDO
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:REYNAGA GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1556 FITZGERALD DR # 116
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2229
Mailing Address - Country:US
Mailing Address - Phone:510-504-3005
Mailing Address - Fax:
Practice Address - Street 1:2168 LA MIRADA DR
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-3216
Practice Address - Country:US
Practice Address - Phone:510-504-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA876124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA876OtherPRIVATE