Provider Demographics
NPI:1437295060
Name:GONZALEZ, JAIME RENE (DDS)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:RENE
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310
Mailing Address - Country:US
Mailing Address - Phone:505-437-7473
Mailing Address - Fax:505-437-0079
Practice Address - Street 1:1022 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:505-437-7473
Practice Address - Fax:505-437-0079
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1873122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist