Provider Demographics
NPI:1497917850
Name:GONZALEZ, LUIS MIGUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MIGUEL
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 1:3141 CAPITAL BLVD
Mailing Address - Street 2:STE 107
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3378
Mailing Address - Country:US
Mailing Address - Phone:919-876-5236
Mailing Address - Fax:
Practice Address - Street 1:3621 CAPE CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4457
Practice Address - Country:US
Practice Address - Phone:910-307-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice