Provider Demographics
NPI:1528398351
Name:GONZALES, BENJAMIN D (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:D
Last Name:GONZALES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16155 NW CORNELL RD
Mailing Address - Street 2:STE 450
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4810
Mailing Address - Country:US
Mailing Address - Phone:503-629-5300
Mailing Address - Fax:503-690-9452
Practice Address - Street 1:16155 NW CORNELL RD
Practice Address - Street 2:STE 450
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4810
Practice Address - Country:US
Practice Address - Phone:503-629-5300
Practice Address - Fax:503-690-9452
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD93761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice