Provider Demographics
NPI:1295873479
Name:VIDAL GONZALEZ, RICARDO L
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:L
Last Name:VIDAL GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 HANOVER CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4326
Mailing Address - Country:US
Mailing Address - Phone:502-296-7536
Mailing Address - Fax:
Practice Address - Street 1:118 SEARS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5014
Practice Address - Country:US
Practice Address - Phone:502-296-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0243381223P0300X
IN12013412A1223P0300X
KY82811223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics