Provider Demographics
NPI:1407373673
Name:GONZALEZ, LIDICE (PHDHP)
Entity Type:Individual
Prefix:
First Name:LIDICE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N ARCH ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2928
Mailing Address - Country:US
Mailing Address - Phone:717-299-6372
Mailing Address - Fax:717-945-1587
Practice Address - Street 1:625 S DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-4509
Practice Address - Country:US
Practice Address - Phone:717-299-6372
Practice Address - Fax:717-945-1587
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH070711124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist