Provider Demographics
NPI:1285202614
Name:GONZALEZ, STEPHANIE IVANA (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:IVANA
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 1:4120 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MALABAR
Mailing Address - State:FL
Mailing Address - Zip Code:32950-4339
Mailing Address - Country:US
Mailing Address - Phone:321-750-7491
Mailing Address - Fax:
Practice Address - Street 1:4789 SW 148TH AVE STE 205
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-2121
Practice Address - Country:US
Practice Address - Phone:954-633-8496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN258951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice