Provider Demographics
NPI:1497721310
Name:GONZALEZ, MARDILY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARDILY
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:PO BOX 195015
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-5015
Mailing Address - Country:US
Mailing Address - Phone:787-763-9190
Mailing Address - Fax:787-763-9587
Practice Address - Street 1:255 CALLE ELEONOR ROOSEVELT
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-2806
Practice Address - Country:US
Practice Address - Phone:787-763-9190
Practice Address - Fax:787-763-9587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice