Provider Demographics
NPI:1770622060
Name:GONZALES DENTAL CLINIC, LTD. A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:GONZALES DENTAL CLINIC, LTD. A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GIROD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-644-2183
Mailing Address - Street 1:318 E CORNERVIEW STREET
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-3152
Mailing Address - Country:US
Mailing Address - Phone:225-644-2183
Mailing Address - Fax:225-647-6975
Practice Address - Street 1:318 E CORNERVIEW STREET
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-3152
Practice Address - Country:US
Practice Address - Phone:225-644-2183
Practice Address - Fax:225-647-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 31441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty