Provider Demographics
NPI:1235262478
Name:GONZALEZ, THERESA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ANN
Last Name:GONZALEZ
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 1:1121 W MICHIGAN ST
Mailing Address - Street 2:ROOM 317
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5211
Mailing Address - Country:US
Mailing Address - Phone:317-274-0387
Mailing Address - Fax:317-274-9544
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:ROOM 317
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5211
Practice Address - Country:US
Practice Address - Phone:317-274-0387
Practice Address - Fax:317-274-9544
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice