Provider Demographics
NPI:1124199567
Name:GONZALES, ANTHONY D (DDS)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:D
Last Name:GONZALES
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:PO BOX 1197
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-1197
Mailing Address - Country:US
Mailing Address - Phone:505-865-4341
Mailing Address - Fax:505-865-4954
Practice Address - Street 1:219 COURTHOURSE RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-865-4341
Practice Address - Fax:505-865-4954
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1351122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist