Provider Demographics
NPI:1528416302
Name:GONZALES, NATHANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
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 1:2838 FREMONT AVE S UNIT 310
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4809
Mailing Address - Country:US
Mailing Address - Phone:952-221-8538
Mailing Address - Fax:
Practice Address - Street 1:10700 FRANCE AVE S STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3693
Practice Address - Country:US
Practice Address - Phone:952-679-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13703122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist