Provider Demographics
NPI:1568596914
Name:GONZALES, KENNETH (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
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 1:6225 SARATOGA BLVD #514
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414
Mailing Address - Country:US
Mailing Address - Phone:361-510-8965
Mailing Address - Fax:
Practice Address - Street 1:5314 EVERHART RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411
Practice Address - Country:US
Practice Address - Phone:361-992-2421
Practice Address - Fax:361-992-6427
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice