Provider Demographics
NPI:1114369188
Name:GONZALEZ, NATHAN TYLER (DDS)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:TYLER
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 350
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-0350
Mailing Address - Country:US
Mailing Address - Phone:254-562-5347
Mailing Address - Fax:254-562-5041
Practice Address - Street 1:300 N. SHERMAN ST.
Practice Address - Street 2:
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667-0350
Practice Address - Country:US
Practice Address - Phone:254-562-5347
Practice Address - Fax:254-562-5041
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX288931223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX412981901Medicaid