Provider Demographics
NPI:1679725196
Name:GONZALEZ, JESUS MANUEL (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:MANUEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:21515 DAVIS MILL RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-4419
Mailing Address - Country:US
Mailing Address - Phone:619-723-1550
Mailing Address - Fax:
Practice Address - Street 1:5250 BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7017
Practice Address - Country:US
Practice Address - Phone:210-349-3368
Practice Address - Fax:210-349-2473
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24142122300000X, 1223S0112X
TXS0161204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery