Provider Demographics
NPI:1619190832
Name:GONZALEZ, JUSTIN JOSIAH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:JOSIAH
Last Name:GONZALEZ
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 1:16414 SAN PEDRO AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2245
Mailing Address - Country:US
Mailing Address - Phone:210-499-0009
Mailing Address - Fax:210-499-0003
Practice Address - Street 1:16414 SAN PEDRO AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2245
Practice Address - Country:US
Practice Address - Phone:210-499-0009
Practice Address - Fax:210-499-0003
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist