Provider Demographics
NPI:1649377839
Name:MONGELOS, GUSTAVO N (DDS)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:N
Last Name:MONGELOS
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 1:4417 CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1402
Mailing Address - Country:US
Mailing Address - Phone:301-213-1024
Mailing Address - Fax:202-362-1045
Practice Address - Street 1:1800 K ST NW STE 1104
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-2235
Practice Address - Country:US
Practice Address - Phone:202-362-1024
Practice Address - Fax:202-362-1045
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC55811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice