Provider Demographics
NPI:1679268866
Name:GONZALES, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W KEMP AVE
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-1024
Mailing Address - Country:US
Mailing Address - Phone:575-308-6204
Mailing Address - Fax:
Practice Address - Street 1:824 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4969
Practice Address - Country:US
Practice Address - Phone:575-622-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDB-2023-0100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist