Provider Demographics
NPI:1164509782
Name:GUNGON, JACQUELYN MIRAVITE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:MIRAVITE
Last Name:GUNGON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 MONUMENT BLVD
Mailing Address - Street 2:SUITE I
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3870
Mailing Address - Country:US
Mailing Address - Phone:925-798-4250
Mailing Address - Fax:925-798-7652
Practice Address - Street 1:1800 MONUMENT BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-3870
Practice Address - Country:US
Practice Address - Phone:925-798-4250
Practice Address - Fax:925-798-7652
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice