Provider Demographics
NPI:1326336769
Name:GONZALEZ, RENE
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:898 APIO CT
Mailing Address - Street 2:
Mailing Address - City:RIO RICO
Mailing Address - State:AZ
Mailing Address - Zip Code:85648-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LOPEZ MATEOS #170
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:SONORA
Practice Address - Zip Code:84000
Practice Address - Country:MX
Practice Address - Phone:631-312-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ4260499122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist