Provider Demographics
NPI:1508079377
Name:GONZALO, LUNA (DDS)
Entity Type:Individual
Prefix:
First Name:LUNA
Middle Name:
Last Name:GONZALO
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 1:1120 WILL RAND DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7620
Mailing Address - Country:US
Mailing Address - Phone:915-449-8589
Mailing Address - Fax:915-833-8796
Practice Address - Street 1:2800 PEDRO S VARELA
Practice Address - Street 2:
Practice Address - City:JUAREZ
Practice Address - State:CHIHUAHUA
Practice Address - Zip Code:32300
Practice Address - Country:MX
Practice Address - Phone:01152656-616-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX567068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist