Provider Demographics
NPI:1134220452
Name:GONZALEZ, GINA (DDS)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16673 CALLE HALEIGH
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-1968
Mailing Address - Country:US
Mailing Address - Phone:310-573-1200
Mailing Address - Fax:310-573-1744
Practice Address - Street 1:900 WILSHIRE BLVD
Practice Address - Street 2:440
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1872
Practice Address - Country:US
Practice Address - Phone:310-451-5557
Practice Address - Fax:310-451-1158
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA391531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice