Provider Demographics
NPI:1558971473
Name:GONZALES, MICHELLE (DMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17747 FOXGLOVE LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2163
Mailing Address - Country:US
Mailing Address - Phone:561-213-5421
Mailing Address - Fax:
Practice Address - Street 1:17747 FOXGLOVE LN
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2163
Practice Address - Country:US
Practice Address - Phone:561-213-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist