Provider Demographics
NPI:1710980180
Name:GONSALVES, GERARD L (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:L
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 MILLBURN AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2670
Mailing Address - Country:US
Mailing Address - Phone:973-763-1300
Mailing Address - Fax:973-763-0800
Practice Address - Street 1:2168 MILLBURN AVE
Practice Address - Street 2:STE 102
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2670
Practice Address - Country:US
Practice Address - Phone:973-763-1300
Practice Address - Fax:973-763-0800
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
NJ22DI016407001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice