Provider Demographics
NPI:1376165324
Name:GONZALEZ, REINOL IGNACIO
Entity Type:Individual
Prefix:
First Name:REINOL
Middle Name:IGNACIO
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 1:14351 SW 29TH CT
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-1037
Mailing Address - Country:US
Mailing Address - Phone:954-258-3902
Mailing Address - Fax:
Practice Address - Street 1:7800 W OAKLAND PARK BLVD STE 114F
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-1122
Practice Address - Country:US
Practice Address - Phone:954-741-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist