Provider Demographics
NPI:1760060313
Name:GONZALES, DYLAN RICHARD
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:RICHARD
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 LEE STREET
Mailing Address - Street 2:MAILBOX 800394
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-5306
Mailing Address - Fax:434-982-4467
Practice Address - Street 1:1215 LEE STREET
Practice Address - Street 2:MAILBOX 800394
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-5306
Practice Address - Fax:434-982-4467
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0116040208390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program