Provider Demographics
NPI:1609401488
Name:GONZALEZ, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1451
Mailing Address - Country:US
Mailing Address - Phone:209-523-6910
Mailing Address - Fax:209-491-0627
Practice Address - Street 1:3125 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1451
Practice Address - Country:US
Practice Address - Phone:209-523-6910
Practice Address - Fax:209-523-6912
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator