Provider Demographics
NPI:1740736453
Name:GONZALES, RYAN RAQUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:RAQUEL
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 1:1061 S STATE ROUTE 260
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4624
Mailing Address - Country:US
Mailing Address - Phone:928-386-2085
Mailing Address - Fax:
Practice Address - Street 1:1061 S STATE ROUTE 260
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4624
Practice Address - Country:US
Practice Address - Phone:928-239-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist