Provider Demographics
NPI:1437162724
Name:GONZALEZ, JUAN RAFAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:RAFAEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:VIEQUES
Mailing Address - State:PR
Mailing Address - Zip Code:00765-0608
Mailing Address - Country:US
Mailing Address - Phone:787-318-7376
Mailing Address - Fax:
Practice Address - Street 1:502 BALDORIOTY ST
Practice Address - Street 2:ISABEL II
Practice Address - City:VIEQUES
Practice Address - State:PR
Practice Address - Zip Code:00765
Practice Address - Country:US
Practice Address - Phone:787-318-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR856122300000X
NY042540122300000X
TX17336-9122300000X
IL019-022361122300000X
OH30-022496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR856OtherDENTAL LICENCE
PR008682OtherREGISTRATION NUM.