Provider Demographics
NPI:1750438925
Name:CORZO, GONZALO (DDS)
Entity type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:CORZO
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 1:5915 LINDENHURST AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3218
Mailing Address - Country:US
Mailing Address - Phone:323-939-0184
Mailing Address - Fax:
Practice Address - Street 1:2028 W PICO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5011
Practice Address - Country:US
Practice Address - Phone:213-380-5506
Practice Address - Fax:213-380-0754
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52366Medicaid