Provider Demographics
NPI:1568740777
Name:GONZALEZ, RICKY OMAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:OMAR
Last Name:GONZALEZ
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:PO BOX 79271
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00984
Mailing Address - Country:US
Mailing Address - Phone:787-553-2738
Mailing Address - Fax:
Practice Address - Street 1:LA TORRE DE PLAZA LAS AMERICAS
Practice Address - Street 2:SUITE 604
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-379-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR31751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics