Provider Demographics
NPI:1790920916
Name:GONZALEZ, EDWARD JOHANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHANN
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 1:590 MITCHELL BLVD
Mailing Address - Street 2:47 ADS/SGGD
Mailing Address - City:LAUGHLIN AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78843-5242
Mailing Address - Country:US
Mailing Address - Phone:830-298-6398
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:96TH MDG/SGDR
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1302
Practice Address - Country:US
Practice Address - Phone:850-883-8785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23956390200000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program