Provider Demographics
NPI:1629136072
Name:GONZALES, ELAINE ANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:ANNE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 THORNTON PL
Mailing Address - Street 2:APT 6C
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:853 BROADWAY
Practice Address - Street 2:SUITE 2001
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4703
Practice Address - Country:US
Practice Address - Phone:212-533-4606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0517981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice