Provider Demographics
NPI:1255439840
Name:GARZA GONGORA, CARLOS A (DDS)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:GARZA GONGORA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 TOWNE LAKE PARKWAY
Mailing Address - Street 2:BUILDING 1300 STE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189
Mailing Address - Country:US
Mailing Address - Phone:678-445-5444
Mailing Address - Fax:678-445-5552
Practice Address - Street 1:2320 TOWNE LAKE PARKWAY
Practice Address - Street 2:BUILDING 1300 STE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:678-445-5444
Practice Address - Fax:678-445-5552
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN0137001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223P0221XDental ProvidersDentistPediatric Dentistry