Provider Demographics
NPI:1174836803
Name:GONZALEZ, IVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVEN
Middle Name:
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 1:11240 MONTWOOD DR STE J
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4248
Mailing Address - Country:US
Mailing Address - Phone:915-201-2539
Mailing Address - Fax:915-613-5082
Practice Address - Street 1:11240 MONTWOOD DR STE J
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4248
Practice Address - Country:US
Practice Address - Phone:915-201-2539
Practice Address - Fax:915-613-5082
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25489332B00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213843004Medicaid