Provider Demographics
NPI:1497994768
Name:GONSALVES, RYAN EMMANUEL (DDS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:EMMANUEL
Last Name:GONSALVES
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 1:104 WATERS EDGE CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5513
Mailing Address - Country:US
Mailing Address - Phone:919-619-4166
Mailing Address - Fax:
Practice Address - Street 1:104 WATERS EDGE CT
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5513
Practice Address - Country:US
Practice Address - Phone:919-619-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC84141223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health