Provider Demographics
NPI:1467046318
Name:MUNOZ GONZALEZ, JUAN PABLO
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:MUNOZ 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 1:78 16TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4770
Mailing Address - Country:US
Mailing Address - Phone:630-699-0749
Mailing Address - Fax:
Practice Address - Street 1:2209 WOOD AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-2930
Practice Address - Country:US
Practice Address - Phone:908-245-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI029937001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program