Provider Demographics
NPI:1124192299
Name:GONZALES, MABEL (DMD)
Entity type:Individual
Prefix:
First Name:MABEL
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
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:VISA ARCOIRIS ST
Mailing Address - Street 2:PG 92 PACIFICA
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976
Mailing Address - Country:US
Mailing Address - Phone:787-758-7790
Mailing Address - Fax:787-758-7790
Practice Address - Street 1:LODI ST
Practice Address - Street 2:571 VILLA CAPRI
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:787-758-7790
Practice Address - Fax:787-758-7790
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4342OtherFIRST MEDICAL
PR9690043OtherHUMANA
PR041613OtherCRUZ AZUL
PR70589OtherPREFERRED MEDICARE CHOICE
PR206238OtherPREFERRED HEALTH PLAN
PR41308GOOtherTRIPLE S