Provider Demographics
NPI:1770710832
Name:VERONICA GONZALEZ
Entity type:Organization
Organization Name:VERONICA GONZALEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-489-0330
Mailing Address - Street 1:JOSE CLEMENTE OROZCO #10122 STE 406
Mailing Address - Street 2:
Mailing Address - City:TIJUANA
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:22000
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:JOSE CLEMENTE OROZCO #10122 STE 406
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22000
Practice Address - Country:MX
Practice Address - Phone:619-489-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMEXUS DENTAL PPO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZMX36206781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty