Provider Demographics
NPI:1679294326
Name:GONZALEZ, KYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
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 1:5231 NW TORINO LAKES CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3238
Mailing Address - Country:US
Mailing Address - Phone:321-372-8325
Mailing Address - Fax:
Practice Address - Street 1:6455 N WICKHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2020
Practice Address - Country:US
Practice Address - Phone:321-420-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27512122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist