Provider Demographics
NPI:1770086621
Name:RODOLFO GONZALEZ
Entity type:Organization
Organization Name:RODOLFO GONZALEZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:8800 AVE VIA DE LA JUVENTUD
Mailing Address - Street 2:
Mailing Address - City:TIJUANA
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:22010
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8800 AVE VIA DE LA JUVENTUD
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:619-488-3200
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty