Provider Demographics
NPI:1649021296
Name:PERALTA GONZALEZ, JORGE EMILIO (DMD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:EMILIO
Last Name:PERALTA GONZALEZ
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 KENILWORTH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1877
Mailing Address - Country:US
Mailing Address - Phone:914-572-1195
Mailing Address - Fax:
Practice Address - Street 1:16 TABER ST UNIT 304
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-4231
Practice Address - Country:US
Practice Address - Phone:914-572-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN10000576122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program