Provider Demographics
NPI:1255450557
Name:GONZALEZ, CARLA W (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:W
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:BUSTILLO-GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1455 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876
Mailing Address - Country:US
Mailing Address - Phone:978-851-7112
Mailing Address - Fax:
Practice Address - Street 1:1455 MAIN ST
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4769
Practice Address - Country:US
Practice Address - Phone:978-851-7112
Practice Address - Fax:978-851-7112
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice