Provider Demographics
NPI:1366016289
Name:ZETA GONZALEZ, KELLY CATHERINE (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CATHERINE
Last Name:ZETA 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 1:7200 CUMBERLAND PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2538
Mailing Address - Country:US
Mailing Address - Phone:925-818-1973
Mailing Address - Fax:
Practice Address - Street 1:12120 RIDGECREST RD STE 203
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5906
Practice Address - Country:US
Practice Address - Phone:760-242-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1075971223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice