Provider Demographics
NPI:1205389988
Name:GONZALEZ, MIRIAM (DMD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6123
Mailing Address - Country:US
Mailing Address - Phone:928-819-8834
Mailing Address - Fax:928-539-5579
Practice Address - Street 1:801 NORTH 2ND AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-8584
Practice Address - Fax:928-627-8949
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ94921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice