Provider Demographics
NPI:1457654824
Name:GONZALEZ, SUSANA (DMD)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16010 NW 57TH AVE UNIT 130
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6710
Mailing Address - Country:US
Mailing Address - Phone:786-536-9411
Mailing Address - Fax:
Practice Address - Street 1:16010 NW 57TH AVE UNIT 130
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6710
Practice Address - Country:US
Practice Address - Phone:786-536-9411
Practice Address - Fax:305-515-3997
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2017-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17960122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist