Provider Demographics
NPI:1871684183
Name:EDELIO GONZALEZ DMD, PA
Entity Type:Organization
Organization Name:EDELIO GONZALEZ DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-826-9642
Mailing Address - Street 1:1191 W 37TH ST
Mailing Address - Street 2:5
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4941
Mailing Address - Country:US
Mailing Address - Phone:305-826-9642
Mailing Address - Fax:305-819-8014
Practice Address - Street 1:1191 W 37TH ST
Practice Address - Street 2:5
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4941
Practice Address - Country:US
Practice Address - Phone:305-826-9642
Practice Address - Fax:305-819-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00013074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0171853000Medicaid