Provider Demographics
NPI:1255142212
Name:GONZALEZ, GWENDOLYN
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-3320
Mailing Address - Country:US
Mailing Address - Phone:914-987-1159
Mailing Address - Fax:
Practice Address - Street 1:115 MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-2949
Practice Address - Country:US
Practice Address - Phone:914-633-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126800000X
NY031430-01124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No126800000XDental ProvidersDental Assistant