Provider Demographics
NPI:1205048469
Name:GONZALES, STACY RICARDO (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:RICARDO
Last Name:GONZALES
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 1:1606 FOREST FERN COURT
Mailing Address - Street 2:
Mailing Address - City:SUGARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479
Mailing Address - Country:US
Mailing Address - Phone:281-303-5727
Mailing Address - Fax:281-530-1901
Practice Address - Street 1:10216 BEECHNUT ST.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-5016
Practice Address - Country:US
Practice Address - Phone:281-530-1900
Practice Address - Fax:281-530-1901
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice