Provider Demographics
NPI:1205953742
Name:GONZALES, LISA R (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10203 LEAVENWORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109
Mailing Address - Country:US
Mailing Address - Phone:913-299-3999
Mailing Address - Fax:913-299-3165
Practice Address - Street 1:10203 LEAVENWORTH ROAD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109
Practice Address - Country:US
Practice Address - Phone:913-299-3999
Practice Address - Fax:913-299-3165
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS64181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice