Provider Demographics
NPI:1518172006
Name:GONZALES, SEBASTIAN ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:ANDREW
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 1:18700 MAIN ST STE 206
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1714
Mailing Address - Country:US
Mailing Address - Phone:714-375-0959
Mailing Address - Fax:714-375-0961
Practice Address - Street 1:18700 MAIN ST STE 206
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1714
Practice Address - Country:US
Practice Address - Phone:714-375-0959
Practice Address - Fax:714-375-0961
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB30931-01Medicaid