Provider Demographics
NPI:1891265831
Name:DR. DIEGO H. GONZALEZ-ORTIZ, DDS, PLLC
Entity Type:Organization
Organization Name:DR. DIEGO H. GONZALEZ-ORTIZ, DDS, PLLC
Other - Org Name:SUPREME DENTAL OF WADESBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:H
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-465-2210
Mailing Address - Street 1:307 N GREEN ST
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-2182
Mailing Address - Country:US
Mailing Address - Phone:704-465-2210
Mailing Address - Fax:704-465-2214
Practice Address - Street 1:307 N GREEN ST
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2182
Practice Address - Country:US
Practice Address - Phone:704-465-2210
Practice Address - Fax:704-465-2214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty