Provider Demographics
NPI:1477679876
Name:GONZALES, JOHN PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:GONZALES
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 1:425 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 7TH ST NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3360
Practice Address - Country:US
Practice Address - Phone:218-335-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND041327Medicaid
ND949039OtherDENTAL SERVICE CORP.
ND000001859NDOtherDELTA DENTAL USA
ND23946OtherBLUE CROSS BLUE SHIELD