Provider Demographics
NPI:1427415652
Name:GONZALEZ, HENDRICK
Entity Type:Individual
Prefix:
First Name:HENDRICK
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 1:620 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-5035
Mailing Address - Country:US
Mailing Address - Phone:805-922-7725
Mailing Address - Fax:805-922-7726
Practice Address - Street 1:620 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-5035
Practice Address - Country:US
Practice Address - Phone:805-922-7725
Practice Address - Fax:805-922-7726
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50604122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50604OtherDENTAL LICENSE