Provider Demographics
NPI:1023740164
Name:PEREZ-GONZALEZ, GABRIEL (DMD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:PEREZ-GONZALEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 GREENCASTLE RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2938
Mailing Address - Country:US
Mailing Address - Phone:770-486-5585
Mailing Address - Fax:
Practice Address - Street 1:195 GREENCASTLE RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2938
Practice Address - Country:US
Practice Address - Phone:770-486-5585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA21418122332Medicaid
GA21418122332OtherMADICAID