Provider Demographics
NPI:1285002048
Name:GONZALES DENTAL CORPORATION
Entity Type:Organization
Organization Name:GONZALES DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-521-0000
Mailing Address - Street 1:11968 BERNARDO PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128
Mailing Address - Country:US
Mailing Address - Phone:858-521-0000
Mailing Address - Fax:858-521-0404
Practice Address - Street 1:11968 BERNARDO PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128
Practice Address - Country:US
Practice Address - Phone:858-521-0000
Practice Address - Fax:858-521-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26408302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization